Care Net Consultants: Incident Reporting Form

Care Net Consultants (Pty) Ltd
Reg 2012/038468/07 · VAT 4620265191

Incident Reporting Form

1. Reporter Details

Full Name*

Job Title*

Contact Number*

Department / Branch*

Date of Report Submission*

2. Incident Details

Date of Incident*

Time of Incident*

Location of Incident*

Was the incident witnessed?*

Yes No

If yes, names of witnesses

3. Type of Incident (tick all that apply)

If other, please specify

4. Description of the Incident

Please describe what happened in as much detail as possible, including the sequence of events.*

5. Individuals Involved

Name	Role / Designation	Injured? (Y/N)	Immediate Action Taken

6. Immediate Action Taken (tick all that apply)

Details of immediate actions taken

7. Injuries / Damage Summary (if applicable)

8. Was the Incident Reported to Your Line Manager?

Yes No

If yes, name & time of notification

9. Data Breach or Confidentiality Concern? (POPIA)

Yes No

If yes, nature of data compromised

10. Suggestions for Prevention / Corrective Action (optional)

11. Signature of Person Reporting

Full Name*

Date*

Signature*

Sign here, drawing with your finger or mouse

Clear or

I confirm the information above is true and correct to the best of my knowledge.

Incident Report Acknowledgment. We acknowledge receipt of your incident reporting form. Please be advised that the matter is currently under investigation. During this process, Human Resources may contact you, as well as any relevant witnesses, to obtain additional information and clarification. Once the investigation has been completed, a final decision will be communicated within seven (7) days of the report being received. Thank you for your cooperation.

Your report is confidential and goes directly to Human Resources. · Secured in line with POPIA.

Care Net Consultants (Pty) Ltd · Your Partner in Workplace Health
Midrand · Elandsfontein · Brackenfell · Gqeberha · and mobile clinics nationwide
+27 60 070 2723 · hr@carenetconsultants.co.za