ACCIDENT / INCIDENT REPORT

1.0 - ACCIDENT / INCIDENT REPORT

  • 1.1 - Immediate Actions Taken: For example; First Aid treatment given, area closed, equipment isolated.

  • 1.2 - Did anyone see the accident / incident?

  • Witness Statements : Get names, contact details, statements and signatures of witnesses.

  • Name, Number and Signature of Witness No.1

  • Name, Number and Signature of Witness No.2

  • Name, Number and Signature of Witness No.3

2.0 - ACCIDENT INVESTIGATION

  • 2.1 - Analysis: What was the cause(s) of the Accident / Incident?

  • 2.2 - Select all of the major contributing factors:

  • 2.5 - Add photos or recordings to support analysis.

3.0 - PREVENTIVE ACTIONS

  • 3.1 - List actions to prevent / minimise risk of recurrence

  • 3.2 - By Whom:

  • 3.3 - By When:

4.0 - REHABILITATION / ACC

  • 4.1 - List suitable alternative duties available and / or potential capabilities or limitations of injured person

  • 4.2 - If Lost Time Injury (LTI) adjust slider to number of days: (LTI if cannot return to work within 24hrs)

  • 4.3 - ACC Claim?

  • ACC Claim #:

5.0 - REVIEW

  • 5.1 - Review and sign agreed actions have been completed, understood and the situation is now satisfactory

  • 5.2 - Analysis & Investigation Satisfactory?

  • 5.3 - Actions Satisfactory?

  • 5.4 - Return to work well managed?

  • 5.5 - Details Adequate?

  • Missing Details Are?

6.0 - CLOSE OUT

  • 6.1 - Review & Close Out Completed By:

  • 6.2 - Final Comments:

  • 6.3 - Person Injured / Involved in Accident / Incident

  • 6.4 - The Concrete People Health & Safety Manager

ACCIDENT / INCIDENT TYPE

7.0 - ACCIDENT OR INCIDENT TYPE:

  • 7.1 - Accident Type:

  • 7.2 - Incident Type:

  • 7.3 - If Serious Harm Injury, ensure company procedures are followed & notify the Department of Labour (DoL)

  • 7.4 - Serious Harm reported by:

  • 7.5 - DoL Advised When?

  • Serious Harm reported by:

8.0 - DETAILS

  • 8.1 - Accident / Incident Date and Time:

  • 8.2 - Shift Stage: Select at what stage of shift accident/incident occurred

  • 8.3 - Name of Person(s) Injured / Involved:

  • Date of Birth:

  • Male / Female:

  • 8.4 - Name of Person(s) Injured / Involved:

  • Date of Birth:

  • Male / Female:

  • 8.5 - Name of Person(s) Injured / Involved:

  • Male / Female:

  • Date of Birth:

  • Additional Name:

  • Name:
  • Name of Person Injured / Involved:

  • Male / Female:

  • Date of Birth:

  • 8.6 - Residential Address: (serious harm accidents only)

  • 8.7 - Person Injured / Involved:

  • Details:

  • Period of Employment Of Injured Person:

  • Address:

  • Ph Number:

  • Company Name:

  • 8.8 - Action Causing Accident / Serious Harm:

  • 8.9 - Object / Condition Cause Of Accident / Serious Harm:

  • 9.0 - Select Which Part(s) Of The Body Were Injured:

  • 9.1 - Nature Of Injury Or Disease

  • 9.2 - What Happened? Give a full description of the incident (include or attach any relevant information such as diagrams and photos).

  • Add Supporting Illustration Here:

  • Add Supporting Media Here:

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