Title Page

  • ABC-WHS-XXX [number] [first] [last]

  • Conducted on

  • Prepared by

  • Personnel

General Details, Individual involved in the incident - To be completed as soon as possible after the incident.

  • Name

  • Location

  • Department

  • Date of Birth

  • Sex

  • Occupation

  • Employment Category

  • Please Specify

Incident Type

  • How would you classify this report?

Incident Details

  • Date and Time of Incident

  • Date and Time the incident was reported

  • To Who was the incident reported?

The Person/Persons involved in the Incident

  • Was the person

  • Please Specify

  • Was the person working alone

  • If No, give the names of co-workers

  • Was the person directly supervised at the time of the incident

  • Add media

  • If Yes, Supervisors Name

  • If No, Was the person

Description of the Incident - as described by the employee (Attach diagrams, sketches or photographs)

  • Where did the Incident Occur

  • Provide photo of scene.

  • What was the person doing at this time

  • What happened unexpectedly

  • How was the Injury or disease sustained

  • What was the quick fix

  • Employee Signature

  • Select date

  • Type of Injury/disease

  • Bodily location of Injury

  • Add media

Initial Treatment Given - to be completed by the First Aider/Supervisor or Manager

  • Initial treatment

  • Details of First Aid given

  • First Aiders Name

  • Returned to Normal Duties

Details of plant equipment used

  • Make

  • Type

  • Description of Equipment

Supervisor in charge of worker

  • Supervisor's Name

  • Were Instruction given to the employee/s prior to the incident

  • If Yes, How

  • If No, Give explanation

  • Did employee/s deviate from instructions

  • If Yes, How

  • What were you doing and what was you location at the time of the incident

  • Supervisor Signature

  • Select date

Contributing Factors Identification Guide


  • Did any fault in equipment/tool/work area contribute to incident?

  • Did the design/quality of the equipment tool/work area contribute to the incident?

  • Did the location/position of the equipment /tool/ work area contribute to the incident?

  • Has the hazardous condition been recognised previously? (e.g. Incident Report)

  • Was there an inspection system to detect hazardous conditions?

  • Did the existing inspection system detect a hazardous condition?

  • Were employee/s informed/aware of the hazardous condition?

  • Was there an acceptable standard of housekeeping in the area?

  • Was there appropriate protective equipment for the job? (e.g. signs, lights, barricades)

  • Did employee know protective equipment was required?

  • Was the correct equipment/tools used for the task?

  • Was there adequate means of access?

  • Was the equipment working within its limitations

  • Was there good visibility?

  • Was there adequate lighting?

  • Was the equipment in a safe condition?

  • Were the roads in good condition?

  • Was it inclement weather?

  • Was worn, slippery or uneven footing present?

  • List any other contributing factors below

Work Systems/Procedures

  • Were there written procedures for this task?

  • Were safe working systems observed? (e.g. isolation procedures)

  • Were there known procedures for this task?

  • Did the written/known procedure/s anticipate the factors which led to the incident?

  • Were the procedures complied with?

  • Had employee/s been instructed/trained in the job procedure/s clearly?

  • Had employee/s been deemed competent and understood the job procedure/s?

  • Did employee/s deviate from written/known procedures?

  • Had employee/s been made aware of any previous incident?

  • Was there a history of a previous incident when carrying out this job in the past?

  • Were any safety devices inoperative at time of incident?

  • List any other contributing factors….

Human/Personal Protective Equipment

  • Were the actions of other person/s contributory?

  • Was employee/s physically capable of doing the task? (e.g. good health, no disability, recovering from illness)

  • Any known personal problems that could have affected employee/s actions? (e.g. stress, disagreement with co-workers, domestic)

  • Was appropriate Personal Protective Equipment (PPE) specified for the task? (e.g. respiratory, gloves, goggles)

  • Did employee/s know that wearing specified PPE was required?

  • Was PPE adequate for the job?

  • Was employee/s wearing specified PPE?

  • Was there frequent Supervisor/employee/s contact to discuss/review hazards and job procedures? (e.g. safety meetings, daily pre-shift meetings.

Analysis: What contributed to the Incident

  • Give Details

What actions has or will be taken to prevent a recurrence

  • Give details


  • Did you finish your shift

  • What time did you leave?

  • Is a Drug and Alcohol test required

  • If Yes, contact the WH&S Manager

  • Employee Signature

  • Accident Investigated by:

  • Managers Signature

  • Form is to be emailed to the incident notification Group, IncidentNotification@casellafamilybrands.com within 24 hours of the Incident.

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