Health & Safety Incident Report

Please record all health and safety incidents as soon as possible.

Travel incident related to business travel are also to be recorded on this form.

Ensure the responsible Navitas Manager has been verbally notified of the incident.

If you do not have all the necessary information, please complete the form with the available information, additional information can be added later.

Select the option that best describe the party involved.

Please enter the name of the person involved in the incident. If this was property damage, please enter "not applicable".

Select the incident type that best describes the event.

Injury information

Select the option that best describe the injury

The bodily location of the most serious original injury or part of the body affected by disease

If you chose “Other” above, please fill in details below

What was the classification that best described the type of injury/illness sustained by the person?

What was the direct cause of the injury sustained and what particular process, equipment or chemical, was

involved?

Illness Information

Please select the most appropriate illness category

Select one

Property Damage Information

What was the direct cause of the property damage and what particular process, equipment or chemical, was involved?

Has the Landlord/property owner been advised of the Property Damage?

Travel Disruption Heading

Near Miss Information

Incident Information

What was the potential cause of the incident and what particular process, equipment or chemical, was involved?

Location within the site where the incident occured

Select the type of emergency event

This item refers to location-wide emergencies that require the activation of the alarm systems, emergency services calls or for the whole location involving everyone (or the majority of staff) at the location.

Type of alarm was appropriate

Were the instructions issued by wardens followed or not

There were enough wardens to cover the requirements of the emergency

Were the wardens easily and quickly identifiable and were they clear in their communications

If your response has been "No" to any of the above please fill this in.

If your response has been "Yes", but you feel something can be improved please fill in this section

Were the instructions issued by wardens followed or not

This item refers to location-wide emergencies that require the activation of the alarm systems, emergency services calls or for the whole location involving everyone (or the majority of staff) at the location.

Type of alarm was appropriate

There were enough wardens to cover the requirements of the emergency

Were the wardens easily and quickly identifiable and were they clear in their communications

If your response has been "No" to any of the above please fill this in.

If your response has been "Yes", but you feel something can be improved please fill in this section

Please outline any steps taken to resolve the incident. If none taken please enter "none".

Provide most applicable further actions to be taken

Briefly outline why the manager has not been not been notified.

If there were witnesses please supply details below

Witness Details
1

Thank you.

If you have any additional documents please click "Submit Event" after which you may attach relevant documents. If you have completed all the details please click the "Submit Event" button. This incident will now be reviewed and escalated to the appropriate manager for action. You will have the opportunity to print a copy for your records.