| Business (PCBU) | [Business name] |
|---|---|
| Reference | [Incident number] |
| Date and time | [Date] |
| Location | [Where it happened] |
| Investigated by | [Name and position] |
| Report date | [Report date] |
| Jurisdiction | New South Wales |
Notification and site rules: ss 35–39 of the Work Health and Safety Act 2011 (NSW). Corrective actions follow the hierarchy of control measures (s 36 of the Work Health and Safety Regulation 2025 (NSW)). This is a draft prepared from the details entered. It does not by itself show that your obligations are met: check it against your workplace, consult the people who will use it, and update it when things change.
1. What happened
[A factual description of the incident]
People involved and witnesses: [Names and roles]
Injury, illness or damage: [Nature of any injury, illness, near miss or damage]
2. Notifying the regulator
Not yet confirmed whether this must be notified to SafeWork NSW. Check it now: notice must be given immediately after becoming aware of a notifiable incident.
3. Sequence of events
- [Events in order, from before the incident to the response]
4. Immediate causes
- [The acts or conditions that directly led to the incident]
5. Contributing factors
[Factors under people, workplace, equipment, procedures and organisation]
6. Root cause
Root cause: [The underlying cause that, if fixed, prevents this happening again]
7. Corrective actions (most effective first)
[Corrective actions, starting with eliminating the hazard]
8. Follow-up
Check by [follow-up date] that each action is done and working. Update the risk assessment and any procedures it affects, and tell the workers involved what was found and changed.
Sign-off
| Investigated by | Name ____________ Signature ____________ Date ________ |
|---|---|
| Reviewed by (manager or officer) | Name ____________ Signature ____________ Date ________ |
Draft prepared with a free tool. Tailor it before use. General information, not legal advice.