Tycen Demolitions Pty Ltd
Accident and Incident Report
Please contact HR or ALLOCATOR and send injured worker with Light duty tasks list.
Reporter's Details
Name of Reporting Person
*
First Name
Last Name
E-mail
You will receive a copy of your report.
Date of Report
/
Day
/
Month
Year
Date Picker Icon
Were There Any Witnesses?
Project Details
Job Number
*
Project Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Principal Contractor
Project Supervisor
Aisake Misa
Dilpreete Singh
Sevaan Zaya
Fiolasi Otuhouma
Nature of the Report.
Injury
Safety Incident
Driving Collision
Near Miss
Person Involved in Incident
Name
First Name
Last Name
Employer
Role of Employee
Employment Start Date
-
Month
-
Day
Year
Date
Employment
Permanent
Casual
Date and Time of Incident
/
Day
/
Month
Year
Date
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01
02
03
04
05
06
07
08
09
10
11
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14
15
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23
:
Hour
00
15
30
45
Minutes
Where did the Incident Occur
Reported to
Initial Treatment
Initial Treatment
Report Only
First Aid
Ambulance
Medical centre or doctor
Hospital
Hospital Name
Hospital Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Centre Name
Medical Centre Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Nature Of Injury
Nature Of Injury
Fractures
Concussion
Contusion
Foreign body
Dislocation
Laceration
Burn
Amputation
Sprain/Strain
Abrasion
Multiple
Emotional
Other
Body Location
Head
Cranium
Eye
Mouth
Ear
Nose
Face
Neck
Other
Trunk
Back
Abdomen
Chest
Pelvis
Other
Arm
Shoulder
Upper arm
Elbow
Forearm
Wrist
Hand
Fingers
Other
Leg
Hip
Thigh
Knee
Shin
Foot
Ankle
Toes
Other
Indicate Injured Areas
Photo of where the accident occured and injury
If you can please take photos of the location and the injury when relevant and email: hr@tycen.com.au
First Aid Completed By:
First Name
Last Name
Position
Job Role
Type of Incident
Type of Incident
Environmental
Falling Object
Handling Object
Stepping On etc
Structural Failure
Fall of Person
Hazardous Substance
Struck By
Manual Handling
Fall From Height Over 2 Meters
Materials Handling
Striking Against
Equipment
Person Slipping or Tripping at same Level
Hand/Power Tools
Caught In etc
Striking buried services (In-ground & Structure)
Foreign Object in the Eye
Electricity
Other
What activity was the individual doing at the time of the accident/incident?
How did the accident occur?
Details of near miss
Submit
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Print Form
Origin
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