1234567890 Incident Record Form 2024

• Location/Branch

• Type of Event

  Injury

  Illness

  Medical Event

  Near Miss/Close Call

  Īncident

• Tick if fatalities occurred during this event

• Tick if this event is notifiable?

Persons Involved

Directly Affected

• Name

• Category

  Employee

  Visitor

  Volunteer

  Visitor

  Contractor

• Is contracted as

  Full-time

  Part-time

  Temporary

  Seasonal

• Position

• Supervisor/Manager Name

• Duration of employment (approx.)

• What reason is visitor present at the time of event

  Select Courier Delivering packages Customer Client Friend/Family member Utility/Maintenance Salesperson Other

  • Courier
  • Delivering packages
  • Customer
  • Client
  • Friend/Family member
  • Utility/Maintenance
  • Salesperson
  • Other

• Describe details of volunteer work, duration, frequency etc

• Has volunteer been inducted

  Yes

  No

  N/A

• Describe details of work, duration, frequency etc

• Had Contractor been inducted

  Yes

  No

  N/A

• How were you directly affected? In what capacity was your role in this event?

  Select Injured Impaired Mental Health Adversely Affected Ill Assisting with first aid/medical treatment Assisting with managing event (traffic, cleanup) Emergency team member

  • Injured
  • Impaired
  • Mental Health Adversely Affected
  • Ill
  • Assisting with first aid/medical treatment
  • Assisting with managing event (traffic, cleanup)
  • Emergency team member

• Contact Phone Number

• Email Address

• Address

• Type of address

  Physical

  Postal

• Sex

  Male

  Female

• Age

• Other notes you that may be of importance, ie Impaired Person

• Continue documenting other Directly Affected Persons or Witnesses details. Once you have the details of all those involved, move on to the next section "The Event"

Witness(s)

• Name

• Category

  Employee

  Visitor

  Volunteer

  Visitor

  Contractor

• Is contracted as

  Full-time

  Part-time

  Temporary

  Seasonal

• Position

• Supervisor/Manager Name

• Duration of employment (approx.)

• What reason is visitor present at the time of event

  Select Courier Delivering packages Customer Client Friend/Family member Utility/Maintenance Salesperson Other

  • Courier
  • Delivering packages
  • Customer
  • Client
  • Friend/Family member
  • Utility/Maintenance
  • Salesperson
  • Other

• Describe details of volunteer work, duration, frequency etc

• Has volunteer been inducted

  Yes

  No

  N/A

• Describe details of work, duration, frequency etc

• Had Contractor been inducted

  Yes

  No

  N/A

• Contact Phone Number

• Email Address

• Address

• Type of address

  Physical

  Postal

• Sex

  Male

  Female

• Age

• Is this person impaired?

• Provide details ie, Hearing impaired

The Event

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• Location of incident. (Specify site location)

• Name of person it was reported by

• Category of person

  Employee

  Visitor

  Volunteer

  Visitor

  Contractor

• To whom was the incident reported?

• Position

• Type of event. Select all that may apply

  Select Injury Illness Medical Event Near Miss/Close Call Īncident

  • Injury
  • Illness
  • Medical Event
  • Near Miss/Close Call
  • Īncident

• What was the potential for severity?

  Minor

  Serious

  Major

  Undetermined

• Causes that contributed to the Near Miss/Close call

  Select Injury Medical Event Lost Time Injury Headache/Dizziness Natural Disaster Plant (excl. vehicle involved) Whilst operating a machine Damage to property Fall from Height Exposure to Mechanical vibration Environmental Causing Illness Broken Limb Sight Impaired Building Evacuation Contractor Human Error Vehicle involved Whilst driving Weather contributed Falls on same Height (includes Slips & Trips) Contact/exposure with hazardous substance (incl. biohazards). (incl. biohazards) Causing Injury Laceration Onsite Machine Failure Drugs/Alcohol possible Whilst manual handling Lack of training Struck against Muscle Stress & Repetitive Movement Notifiable Event Strained Muscle Mental Health adversely effected Offsite 1 + persons effected Stationary Struck by moving/falling objects Contact with Electricity Inadequately trained Inadequately inducted Environmental Fatigue Impaired person(s) Children Animal Unstable Load Unstable ground Incorrect Labelling

  • Injury
  • Medical Event
  • Lost Time Injury
  • Headache/Dizziness
  • Natural Disaster
  • Plant (excl. vehicle involved)
  • Whilst operating a machine
  • Damage to property
  • Fall from Height
  • Exposure to Mechanical vibration
  • Environmental
  • Causing Illness
  • Broken Limb
  • Sight Impaired
  • Building Evacuation
  • Contractor
  • Human Error
  • Vehicle involved
  • Whilst driving
  • Weather contributed
  • Falls on same Height (includes Slips & Trips)
  • Contact/exposure with hazardous substance (incl. biohazards).
  • (incl. biohazards)
  • Causing Injury
  • Laceration
  • Onsite
  • Machine Failure
  • Drugs/Alcohol possible
  • Whilst manual handling
  • Lack of training
  • Struck against
  • Muscle Stress & Repetitive Movement
  • Notifiable Event
  • Strained Muscle
  • Mental Health adversely effected
  • Offsite
  • 1 + persons effected
  • Stationary
  • Struck by moving/falling objects
  • Contact with Electricity
  • Inadequately trained
  • Inadequately inducted
  • Environmental
  • Fatigue
  • Impaired person(s)
  • Children
  • Animal
  • Unstable Load
  • Unstable ground
  • Incorrect Labelling

• What potentially could have happened?

• Causes that contributed to the event:

  Select Injury Medical Event Lost Time Injury Headache/Dizziness Natural Disaster Plant (excl. vehicle involved) Whilst operating a machine Damage to property Fall from Height Exposure to Mechanical vibration Environmental Causing Illness Broken Limb Sight Impaired Building Evacuation Contractor Human Error Vehicle involved Whilst driving Weather contributed Falls on same Height (includes Slips & Trips) Contact/exposure with hazardous substance (incl. biohazards). (incl. biohazards) Causing Injury Laceration Onsite Machine Failure Drugs/Alcohol possible Whilst manual handling Lack of training Struck against Muscle Stress & Repetitive Movement Notifiable Event Strained Muscle Mental Health adversely effected Offsite 1 + persons effected Stationary Struck by moving/falling objects Contact with Electricity Inadequately trained Inadequately inducted Environmental Fatigue Impaired person(s) Children Animal Unstable Load Unstable ground Incorrect Labelling

  • Injury
  • Medical Event
  • Lost Time Injury
  • Headache/Dizziness
  • Natural Disaster
  • Plant (excl. vehicle involved)
  • Whilst operating a machine
  • Damage to property
  • Fall from Height
  • Exposure to Mechanical vibration
  • Environmental
  • Causing Illness
  • Broken Limb
  • Sight Impaired
  • Building Evacuation
  • Contractor
  • Human Error
  • Vehicle involved
  • Whilst driving
  • Weather contributed
  • Falls on same Height (includes Slips & Trips)
  • Contact/exposure with hazardous substance (incl. biohazards).
  • (incl. biohazards)
  • Causing Injury
  • Laceration
  • Onsite
  • Machine Failure
  • Drugs/Alcohol possible
  • Whilst manual handling
  • Lack of training
  • Struck against
  • Muscle Stress & Repetitive Movement
  • Notifiable Event
  • Strained Muscle
  • Mental Health adversely effected
  • Offsite
  • 1 + persons effected
  • Stationary
  • Struck by moving/falling objects
  • Contact with Electricity
  • Inadequately trained
  • Inadequately inducted
  • Environmental
  • Fatigue
  • Impaired person(s)
  • Children
  • Animal
  • Unstable Load
  • Unstable ground
  • Incorrect Labelling

• Detailed description of Event/Illness or Near Miss/Close call

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

• What corrective actions if any were carried out immediately of event? Provide details

• Causes that contributed to event

  Select Injury Medical Event Lost Time Injury Headache/Dizziness Natural Disaster Plant (excl. vehicle involved) Whilst operating a machine Damage to property Fall from Height Exposure to Mechanical vibration Environmental Causing Illness Broken Limb Sight Impaired Building Evacuation Contractor Human Error Vehicle involved Whilst driving Weather contributed Falls on same Height (includes Slips & Trips) Contact/exposure with hazardous substance (incl. biohazards). (incl. biohazards) Causing Injury Laceration Onsite Machine Failure Drugs/Alcohol possible Whilst manual handling Lack of training Struck against Muscle Stress & Repetitive Movement Notifiable Event Strained Muscle Mental Health adversely effected Offsite 1 + persons effected Stationary Struck by moving/falling objects Contact with Electricity Inadequately trained Inadequately inducted Environmental Fatigue Impaired person(s) Children Animal Unstable Load Unstable ground Incorrect Labelling

  • Injury
  • Medical Event
  • Lost Time Injury
  • Headache/Dizziness
  • Natural Disaster
  • Plant (excl. vehicle involved)
  • Whilst operating a machine
  • Damage to property
  • Fall from Height
  • Exposure to Mechanical vibration
  • Environmental
  • Causing Illness
  • Broken Limb
  • Sight Impaired
  • Building Evacuation
  • Contractor
  • Human Error
  • Vehicle involved
  • Whilst driving
  • Weather contributed
  • Falls on same Height (includes Slips & Trips)
  • Contact/exposure with hazardous substance (incl. biohazards).
  • (incl. biohazards)
  • Causing Injury
  • Laceration
  • Onsite
  • Machine Failure
  • Drugs/Alcohol possible
  • Whilst manual handling
  • Lack of training
  • Struck against
  • Muscle Stress & Repetitive Movement
  • Notifiable Event
  • Strained Muscle
  • Mental Health adversely effected
  • Offsite
  • 1 + persons effected
  • Stationary
  • Struck by moving/falling objects
  • Contact with Electricity
  • Inadequately trained
  • Inadequately inducted
  • Environmental
  • Fatigue
  • Impaired person(s)
  • Children
  • Animal
  • Unstable Load
  • Unstable ground
  • Incorrect Labelling

• Describe Illness

• Possible cause:

Treatment

• What treatment was administered at time of event?

  Select First-Aid Medical None Emergency Services were required

  • First-Aid
  • Medical
  • None
  • Emergency Services were required

• Provide details

• Were medicines given?

  Yes

  No

  N/A

• Provide details if known (ie Name(s), dosage(s), time given such immediately etc)

Ongoing Treatment

• Was further medical treatment required?

  Yes

  No

  N/A

• Provide details, if known of treatment centre, treatment, outcome etc

• Once all details of ongoing treatment has been provided move onto next section "Damage to Property"

Damage to Property/Vehicle

• Property Damage:

  N/a

  Vehicle

  Equipment

  Private Property

  Plant

• Identifying features ie Make/Model, colour, year

• Registration Plate

• Provide as many details as possible ie address, clothing

• Description ie Make/Model, Machine ID

• Approx. age if known

• Severity of damage

  None

  Minor

  Serious

  Major

• Description of damage

• Estimated cost of damage:

• Photo of damage.

  Media

Post Event

Corrective Actions

• What corrective actions need to be actioned to reduce the risk of event reoccurring? Provide details

Worksafe

• Tick if Worksafe needs to be notified

• Have the been notified already?

  Yes

  No

  N/A

• When

  Date

• Name of person who notified Worksafe

• Position

• Is there further follow up actions required by Worksafe?

  Yes

  No

  N/A
Training required

• Details of training to be carried out

Admin Follow Up Tasks

• Incident Event Register updated

• Does this require an Investigation Record Form to be completed?

  Yes

  No

  N/A

• Does Hazard Register need to be updated?

• Event communicated to team

  Yes

  Scheduled

  Other

• Provide details ie Email, TB Meeting (include dates in case evidence is required)

• Provide details

Return to work

• Provide details of return to work plan

  Modified duties

  Full recovery, normal duties

  Work from home

  To be determined

  Other

• Has a Return to Work Plan been completed?

  Yes

  No

  N/A

Signatures

• Please ensure that signatures are obtained from all individuals referenced in this report.

Add signatures here.

• By signing, you acknowledge that you have read and reviewed the document and confirm its accuracy and truthfulness.

• Name

  Sign

• Yes

  No

  N/A

Additional Notes/Photos

• Additional comments, evidence

• Add in any photos

  Media

• Add in any other notes