Is this incident report form really free?

Yes — 100% free, no signup required. Fill it out online, print a completed copy, or download a blank PDF for your workplace.

Is this form compliant with Australian WHS regulations?

Yes. It includes all fields required under the Work Health and Safety Act 2011 including notifiable incident assessment, DRSABCD primary survey, and vital signs monitoring.

Can I save my progress?

Yes — the form auto-saves to your browser. Come back later and your data will still be there. Your data never leaves your device.

What is the Glasgow Coma Scale (GCS)?

GCS is a clinical scale to assess consciousness after a head injury. It measures eye opening (1-4), verbal response (1-5), and motor response (1-6) for a total score of 3-15. This form auto-calculates it.

When do I need to notify the regulator?

Under WHS law, you must notify the regulator immediately for deaths, serious injuries (amputation, head injury, spinal injury, burns, etc.), and dangerous incidents. This form includes a notifiable incident assessment checklist to help you determine if notification is required.

Free Workplace Incident Report Form — Fill Online or Download PDF

1 Incident Reference

Incident / Report Number

Date of Report

Time of Report

Severity Rating

2 Organisation & Site Details

Organisation / Employer Name

ABN

Site / Workplace Address (include state and postcode)

Site Phone

Department / Area

Supervisor / Manager Name

Supervisor Phone

3 Patient (Injured Person) Details

Family Name

Given Names

Sex

Date of Birth

Age

Home Address (include state and postcode)

Phone

Occupation / Job Title

Employment Status

Employee ID / Badge No.

Emergency Contact Name

Relationship

Emergency Contact Phone

4 Incident Details

Date of Incident

Time of Incident

Exact Location Where Incident Occurred

Incident Type

Mechanism of Injury

Body Part Injured

What was the patient doing at the time?

Describe exactly what happened (sequence of events)

Equipment, substances, or objects involved

Were safety controls in place?

Yes — all controls in place Partially — some controls missing No — controls absent or bypassed N/A

5 Medical History (AMPLE)

Allergies

Current Medications

Last Oral Intake (food/drink)

Events Leading to Incident

6 Primary Survey (DRSABCD)

D

Danger

R

Response

S

Send for help

A

Airway

B

Breathing

C

CPR

D

Defibrillator

Level of Consciousness (AVPU)

A — Alert V — Voice responsive P — Pain responsive U — Unresponsive

Primary Survey Notes

7 Vital Signs Monitoring

Observation	Initial	+5 min	+10 min	+15 min	+20 min	Handover
Time (HH:MM)
Pulse (bpm)
Pulse Quality
Resp. Rate (/min)
Resp. Quality
SpO₂ (%)
Blood Pressure
Temp (°C)
BGL (mmol/L)
Pain (0–10)
Pupils (PEARL)
Skin (colour/temp)
GCS (/15)

Pulse quality: S=Strong, W=Weak, I=Irregular | Resp quality: N=Normal, S=Shallow, L=Laboured, D=Distressed | Pupils: E=Equal, U=Unequal, D=Dilated

8 Glasgow Coma Scale (GCS) Reference

GCS Total

Interpretation

9 Injury Body Map & Treatment

Injury Type

Description & Treatment of Injury / Illness

10 First Aid Kit Items Used

Kit Name / ID / Location

Item

Qty

Item

Qty

Record all items used so the kit can be restocked. Log this in FirstAidLog to auto-update inventory.

11 Witnesses

Witness 1 — Full Name

Phone

Role / Position

Witness 1 — Statement Summary

Witness 2 — Full Name

Phone

Role / Position

Witness 2 — Statement Summary

12 Discharge & Outcome

Patient Refused Treatment?

No Yes — witness name:

Discharged How?

Returned to duties Returned to modified duties Sent home Own doctor / GP Hospital (own transport) Ambulance called Deceased Other:

Time of Discharge / Handover

Ambulance Service Number

Hospital Name

Follow-up Actions Required

13 Notifiable Incident Assessment

Is This a Notifiable Incident?

No Yes — notify regulator immediately Uncertain — escalate to WHS manager

State / Territory Regulator

Regulator Notification Date/Time

Regulator Reference Number

14 Root Cause & Contributing Factors

Root Cause Analysis

15 Corrective Actions

Immediate Actions Taken

Corrective Action 1

Responsible Person

Due Date

Corrective Action 2

Responsible Person

Due Date

Corrective Action 3

Responsible Person

Due Date

Hierarchy of Controls Applied

Elimination Substitution Engineering controls Administrative controls PPE

16 Sign-Off

First Aider Name & Signature

First Aid Cert No.

Cert Expiry

Patient Signature

Date

Supervisor / Manager Signature

Date

Workplace Incident Report Form

Workplace Incident & Patient Report

Eye Opening (E)

Verbal Response (V)

Motor Response (M)

Injury Type

Under WHS Act 2011, you MUST notify the regulator immediately if the incident involves:

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