Title Page
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ABC-WHS-XXX [number] [first] [last]
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Conducted on
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Prepared by
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Personnel
General Details, Individual involved in the incident - To be completed as soon as possible after the incident.
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Name
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Location
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Department
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Date of Birth
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Sex
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Occupation
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Employment Category
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Please Specify
Incident Type
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How would you classify this report?
Incident Details
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Date and Time of Incident
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Date and Time the incident was reported
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To Who was the incident reported?
The Person/Persons involved in the Incident
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Was the person
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Please Specify
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Was the person working alone
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If No, give the names of co-workers
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Was the person directly supervised at the time of the incident
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Add media
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If Yes, Supervisors Name
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If No, Was the person
Description of the Incident - as described by the employee (Attach diagrams, sketches or photographs)
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Where did the Incident Occur
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Provide photo of scene.
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What was the person doing at this time
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What happened unexpectedly
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How was the Injury or disease sustained
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What was the quick fix
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Employee Signature
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Select date
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Type of Injury/disease
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Bodily location of Injury
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Add media
Initial Treatment Given - to be completed by the First Aider/Supervisor or Manager
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Initial treatment
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Details of First Aid given
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First Aiders Name
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Returned to Normal Duties
Details of plant equipment used
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Make
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Type
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Description of Equipment
Supervisor in charge of worker
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Supervisor's Name
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Were Instruction given to the employee/s prior to the incident
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If Yes, How
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If No, Give explanation
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Did employee/s deviate from instructions
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If Yes, How
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What were you doing and what was you location at the time of the incident
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Supervisor Signature
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Select date
Contributing Factors Identification Guide
Equipment/Enviroment
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Did any fault in equipment/tool/work area contribute to incident?
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Did the design/quality of the equipment tool/work area contribute to the incident?
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Did the location/position of the equipment /tool/ work area contribute to the incident?
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Has the hazardous condition been recognised previously? (e.g. Incident Report)
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Was there an inspection system to detect hazardous conditions?
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Did the existing inspection system detect a hazardous condition?
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Were employee/s informed/aware of the hazardous condition?
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Was there an acceptable standard of housekeeping in the area?
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Was there appropriate protective equipment for the job? (e.g. signs, lights, barricades)
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Did employee know protective equipment was required?
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Was the correct equipment/tools used for the task?
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Was there adequate means of access?
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Was the equipment working within its limitations
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Was there good visibility?
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Was there adequate lighting?
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Was the equipment in a safe condition?
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Were the roads in good condition?
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Was it inclement weather?
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Was worn, slippery or uneven footing present?
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List any other contributing factors below
Work Systems/Procedures
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Were there written procedures for this task?
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Were safe working systems observed? (e.g. isolation procedures)
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Were there known procedures for this task?
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Did the written/known procedure/s anticipate the factors which led to the incident?
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Were the procedures complied with?
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Had employee/s been instructed/trained in the job procedure/s clearly?
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Had employee/s been deemed competent and understood the job procedure/s?
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Did employee/s deviate from written/known procedures?
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Had employee/s been made aware of any previous incident?
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Was there a history of a previous incident when carrying out this job in the past?
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Were any safety devices inoperative at time of incident?
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List any other contributing factors….
Human/Personal Protective Equipment
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Were the actions of other person/s contributory?
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Was employee/s physically capable of doing the task? (e.g. good health, no disability, recovering from illness)
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Any known personal problems that could have affected employee/s actions? (e.g. stress, disagreement with co-workers, domestic)
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Was appropriate Personal Protective Equipment (PPE) specified for the task? (e.g. respiratory, gloves, goggles)
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Did employee/s know that wearing specified PPE was required?
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Was PPE adequate for the job?
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Was employee/s wearing specified PPE?
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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
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Give Details
What actions has or will be taken to prevent a recurrence
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Give details
Declaration
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Did you finish your shift
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What time did you leave?
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Is a Drug and Alcohol test required
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If Yes, contact the WH&S Manager
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Employee Signature
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Accident Investigated by:
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Managers Signature
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Form is to be emailed to the incident notification Group, IncidentNotification@casellafamilybrands.com within 24 hours of the Incident.
