Information
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Client Name:
- A.J.RUSSELL
- A.W BURNS LTD (ALEX)
- APOLLO PROJECTS
- AZTECH FARM BUILDINGS
- BNC CONTRACTORS
- BRACEWELL
- BRIAN PERRY CIVIL
- BRYMER GROUP
- COLLIN DOWNS
- CONSET
- CONSTRUCT
- CONSTRUCTION ADVANTAGE
- DAVID REID HOMES
- DAVIES CONSTRUCTION
- DOMINION CONSTRUCTORS
- DOWNER
- DOWNEYS
- EDL
- EBERTS
- FLETCHERS
- FOSTERS
- FULTON HOGAN
- GIBBONS
- GELLERTS
- HAWKINS
- HEB
- HIGHRISE
- ICL
- INTERBLOCK
- K.I.BUILDERS
- LIVINGSTONE
- LOBELL
- MARIN
- MARRA
- MURPHY PROPERTIES
- MURTAGH CONSTRUCTION
- NAYLOR LOVE
- PERRY PROPERTIES
- Q CONSTRUCTION
- ROB SHELTON BUILDERS
- SAM PEMBERTON
- SAVORY CONSTRUCTION
- SLAB SPECIALIST
- STRONG LINE BUILDING
- SUPERMAC HOLDINGS
- TEAM SPORT SURFACES
- TIGER TURF
- TRANDA CONSTRUCTION
- V.N.C PROJECTS
- WATTS & HUGHES
- YEOMAN CONSTRUCTION
- OTHER
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OTHER:
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Project Name:
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Project / Site Location:
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Date and Time of investigation:
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Investigators Name:
- CHARMAN, Raymond
- DUNSTAN, Dexta
- OLSEN, Glen
- ROBERTSON, Robert
- SAVAGE, Malcolm
- WRATHALL, Wayne
- PAPA, Aaron
- GILBY, Ben
ACCIDENT / INCIDENT REPORT
1.0 - ACCIDENT / INCIDENT REPORT
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1.1 - Immediate Actions Taken: For example; First Aid treatment given, area closed, equipment isolated.
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1.2 - Did anyone see the accident / incident?
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Witness Statements : Get names, contact details, statements and signatures of witnesses.
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Name, Number and Signature of Witness No.1
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Name, Number and Signature of Witness No.2
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Name, Number and Signature of Witness No.3
2.0 - ACCIDENT INVESTIGATION
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2.1 - Analysis: What was the cause(s) of the Accident / Incident?
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2.2 - Select all of the major contributing factors:
- Hazard not identified
- Significant hazard involved
- Incorrect work method / practices
- Lack of PPE
- Lack of training
- Plant / equipment failure
- Stress / fatigue / impairment
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2.5 - Add photos or recordings to support analysis.
3.0 - PREVENTIVE ACTIONS
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3.1 - List actions to prevent / minimise risk of recurrence
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3.2 - By Whom:
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3.3 - By When:
4.0 - REHABILITATION / ACC
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4.1 - List suitable alternative duties available and / or potential capabilities or limitations of injured person
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4.3 - ACC Claim?
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ACC Claim #:
5.0 - REVIEW
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5.1 - Review and sign agreed actions have been completed, understood and the situation is now satisfactory
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5.2 - Analysis & Investigation Satisfactory?
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5.3 - Actions Satisfactory?
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5.4 - Return to work well managed?
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5.5 - Details Adequate?
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Missing Details Are?
6.0 - CLOSE OUT
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6.1 - Review & Close Out Completed By:
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6.2 - Final Comments:
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6.3 - Person Injured / Involved in Accident / Incident
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6.4 - The Concrete People Health & Safety Manager
ACCIDENT / INCIDENT TYPE
7.0 - ACCIDENT OR INCIDENT TYPE:
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7.1 - Accident Type:
- Serious Harm
- Lost Time Injury (LTI)
- Medical Treatment
- First Aid Only
- No Treatment
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7.2 - Incident Type:
- Near Miss
- Equipment Failure
- Property Damage
- Environmental Incident
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7.3 - If Serious Harm Injury, ensure company procedures are followed & notify the Department of Labour (DoL)
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7.4 - Serious Harm reported by:
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7.5 - DoL Advised When?
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Serious Harm reported by:
8.0 - DETAILS
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8.1 - Accident / Incident Date and Time:
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8.2 - Shift Stage: Select at what stage of shift accident/incident occurred
- Before
- Start
- 1/4
- 1/2
- 3/4
- Finished
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8.3 - Name of Person(s) Injured / Involved:
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Date of Birth:
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Male / Female:
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8.4 - Name of Person(s) Injured / Involved:
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Date of Birth:
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Male / Female:
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8.5 - Name of Person(s) Injured / Involved:
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Male / Female:
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Date of Birth:
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Additional Name:
Name:
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Name of Person Injured / Involved:
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Male / Female:
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Date of Birth:
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8.6 - Residential Address: (serious harm accidents only)
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8.7 - Person Injured / Involved:
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Details:
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Period of Employment Of Injured Person:
- 1st Week
- 1st Month
- 1 - 6 Months
- 6 Months - 1 Year
- 1 Year - 5 Years
- Over 5 Years
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Address:
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Ph Number:
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Company Name:
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8.8 - Action Causing Accident / Serious Harm:
- SLIP OR TRIP
- NOISE OR PRESSURE
- LIFTING, STRETCH, STRAIN
- BIOLOGICAL FACTORS
- MENTAL STRESS
- FALL FROM HEIGHT
- HITTING OBJECTS WITH PART OF BODY
- BEING HIT BY MOVING OBJECTS
- HEAT, RADIATION OR ENERGY
- CHEMICAL OR OTHER SUBSTANCES
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8.9 - Object / Condition Cause Of Accident / Serious Harm:
- Machinery or (mainly) fixed plant
- Mobile plant or transport
- Powered equipment, tool or appliance
- Non powered hand tool, appliance or equipment
- Chemical or chemical product
- Material or substance
- Environmental exposure (e.g. dust, gas)
- Animal, human or biological agency
- Bacteria or virus
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9.0 - Select Which Part(s) Of The Body Were Injured:
- Head / Face
- Ear (left)
- Ear (right)
- Shoulder (left)
- Shoulder (right)
- Back / Spine / Neck
- Chest / Abdomen / Pelvis
- Arm / Elbow (left)
- Arm / Elbow (right)
- Wrist / Hand (left)
- Wrist / Hand (right)
- Finger / Thumb (left)
- Finger / Thumb (right)
- Leg / Knee (left)
- Leg / Knee (right)
- Ankle / Foot / Toes (left)
- Ankle / Foot / Toes (right)
- Internal Pain
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9.1 - Nature Of Injury Or Disease
- Superficial Injury
- Open Wound
- Puncture Wound
- Fracture
- Dislocation
- Sprain or Strain
- Bruising or Crushing
- Burns
- Poisoning or Toxic Effects
- Internal Injury
- Hearing Loss
- Eye Injury
- Gradual Process Injury
- Amputation
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9.2 - What Happened? Give a full description of the incident (include or attach any relevant information such as diagrams and photos).
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Add Supporting Illustration Here:
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Add Supporting Media Here:
