Sterilisation INCIDENT REPORTING FORM Department Use this form to report any workplace accident, injury, incident, close call or illness. Return completed form to the Operations Supervisor or Management. This Is documentingan: Injury First Aid Incident Close Call Observation Details of person Injured or Involved (to be filled In by person Injuredvolved If possible) Person Compelting Report: Date: Person(s) Involved: Event Details: Date of Event: Location of Event: Time of Event: Witnesses Description of Events (Describe tasks being performed and sequence of events): "If more space is required please use the back of this sheet Was event/Injury caused by an unsafe act (activity or movement or an unsafe condition (machinery or weather)? Please explain: TO BE COMPLETED ONLY IF LOST TIMEANJURY OR FIRST AID WAS REQUIRED Type of Injury sustained Cause of lost timeInjury or first ald Was medical treatment necessary Yes No If yes, name of hospital or physician