Accident/Incident/Near Miss Report - Including Investigation

• Document No.

• Brief description - e.g, minor injury, near miss, serious incident etc.

• Client / Site / Project

  Select

• Report completed on

  Date

• Prepared by - full name

  Select
• Location
  Address

Accident/Incident/Near Miss Details - the situation

• Date & Time

  Date
• Location
  Address

• Priority

  Urgent

  High

  Medium

  Low

  Trivial

• What type of situation are you reporting?

  Select Hazard Near-Miss Slip & Fall Accident Injury Theft Fire Property Damage Fatality Illness Other Reportable / Notifiable Loss Time

  • Hazard
  • Near-Miss
  • Slip & Fall
  • Accident
  • Injury
  • Theft
  • Fire
  • Property Damage
  • Fatality
  • Illness
  • Other
  • Reportable / Notifiable
  • Loss Time

• Name of on-duty supervisor at time of the situation you are reporting?

  Select

• Is immediate medical attention required?

  Yes

  No

• If the situation involves a fatality.

• Notify emergency services immediately and do not disturb the incident scene unless it is necessary to prevent further injuries of other parties and it is SAFE FOR YOU TO DO SO.

• Notify Theo Smolenaers on Ph: 0417 496 082 AFTER contacting emergency services

• Is the situation notifiable to SafeWork NSW?

  Yes

  No

• Notify Theo Smolenaers on Ph: 0417 496 082 who will contact SafeWork NSW

Describe What Happened

• Describe what happened. Please be detailed but state only facts.

• What were the weather / environmental conditions at the time of the incident?

  Select Clear Cloudy Rain Snow Windy Heatwave Haze Other

  • Clear
  • Cloudy
  • Rain
  • Snow
  • Windy
  • Heatwave
  • Haze
  • Other

Record Evidence and Information

People involved

• Please document all people involved in this incident, including yourself (the person reporting the incident). Click on the down arrow next to Person 1 and then click on + Person to add up to 2 more people. If there are more people involved create an additional report.

Person

Person 1

• Full Name

• Contact phone number

• What is this person's relationship to the situation? (select all that apply)

  Select Reporter of incident Injured person Witness Primary person involved Secondary Involvement On-duty supervisor Investigator Suspect Other

  • Reporter of incident
  • Injured person
  • Witness
  • Primary person involved
  • Secondary Involvement
  • On-duty supervisor
  • Investigator
  • Suspect
  • Other

• Has this person sustained an injury?

  Yes

  No

Injury Details

• Type of injury or illness? (select all that apply)

  Select Not Applicable Superficial Open Wound Fatality Concussion Sprain Respiratory Eye Injury Burns Fracture Electrocution Fall Strain Dislocation Struck by object Entanglement Assault Muscle & Tendon Nerve & spinal cord Amputation Intracranial Other Injury

  • Not Applicable
  • Superficial
  • Open Wound
  • Fatality
  • Concussion
  • Sprain
  • Respiratory
  • Eye Injury
  • Burns
  • Fracture
  • Electrocution
  • Fall
  • Strain
  • Dislocation
  • Struck by object
  • Entanglement
  • Assault
  • Muscle & Tendon
  • Nerve & spinal cord
  • Amputation
  • Intracranial
  • Other Injury

• Parts of body affected? (select all that apply)

  Select Not Applicable General Ailment Head Eye (Left) Eye (Right) Ear Nose Throat Neck Back (Upper) Back (Lower) Arm - Upper (Right) Arm - Upper (Left) Arm - Elbow (Right) Arm - Elbow (Left) Arm - Forearm (Right) Arm - Forearm (Left) Wrist (Right) Wrist (Left) Hand (Right) Hand (Left) Chest Abdominal / Stomach Groin / Anus Leg - Upper (Right) Leg - Upper (Left) Leg - Knee (Right) Leg - Knee (Left) Leg - Lower (Right) Leg - Lower (Left) Ankle (Right) Ankle (Left) Foot (Right) Foot (Left) Shoulder (Left) Shoulder (Right) Other

  • Not Applicable
  • General Ailment
  • Head
  • Eye (Left)
  • Eye (Right)
  • Ear
  • Nose
  • Throat
  • Neck
  • Back (Upper)
  • Back (Lower)
  • Arm - Upper (Right)
  • Arm - Upper (Left)
  • Arm - Elbow (Right)
  • Arm - Elbow (Left)
  • Arm - Forearm (Right)
  • Arm - Forearm (Left)
  • Wrist (Right)
  • Wrist (Left)
  • Hand (Right)
  • Hand (Left)
  • Chest
  • Abdominal / Stomach
  • Groin / Anus
  • Leg - Upper (Right)
  • Leg - Upper (Left)
  • Leg - Knee (Right)
  • Leg - Knee (Left)
  • Leg - Lower (Right)
  • Leg - Lower (Left)
  • Ankle (Right)
  • Ankle (Left)
  • Foot (Right)
  • Foot (Left)
  • Shoulder (Left)
  • Shoulder (Right)
  • Other

• What was the cause of this injury or illness?

  Select

Person 2

• Is there another person involved?

  Yes

  No

• Full Name

• Contact phone number

• What is this person's relationship to the situation? (select all that apply)

  Select Reporter of incident Injured person Witness Primary person involved Secondary Involvement On-duty supervisor Investigator Suspect Other

  • Reporter of incident
  • Injured person
  • Witness
  • Primary person involved
  • Secondary Involvement
  • On-duty supervisor
  • Investigator
  • Suspect
  • Other

• Has this person sustained an injury?

  Yes

  No

Injury Details

• Type of injury or illness? (select all that apply)

  Select Not Applicable Superficial Open Wound Fatality Concussion Sprain Respiratory Eye Injury Burns Fracture Electrocution Fall Strain Dislocation Struck by object Entanglement Assault Muscle & Tendon Nerve & spinal cord Amputation Intracranial Other Injury

  • Not Applicable
  • Superficial
  • Open Wound
  • Fatality
  • Concussion
  • Sprain
  • Respiratory
  • Eye Injury
  • Burns
  • Fracture
  • Electrocution
  • Fall
  • Strain
  • Dislocation
  • Struck by object
  • Entanglement
  • Assault
  • Muscle & Tendon
  • Nerve & spinal cord
  • Amputation
  • Intracranial
  • Other Injury

• Parts of body affected? (select all that apply)

  Select Not Applicable General Ailment Head Eye (Left) Eye (Right) Ear Nose Throat Neck Back (Upper) Back (Lower) Arm - Upper (Right) Arm - Upper (Left) Arm - Elbow (Right) Arm - Elbow (Left) Arm - Forearm (Right) Arm - Forearm (Left) Wrist (Right) Wrist (Left) Hand (Right) Hand (Left) Chest Abdominal / Stomach Groin / Anus Leg - Upper (Right) Leg - Upper (Left) Leg - Knee (Right) Leg - Knee (Left) Leg - Lower (Right) Leg - Lower (Left) Ankle (Right) Ankle (Left) Foot (Right) Foot (Left) Shoulder (Left) Shoulder (Right) Other

  • Not Applicable
  • General Ailment
  • Head
  • Eye (Left)
  • Eye (Right)
  • Ear
  • Nose
  • Throat
  • Neck
  • Back (Upper)
  • Back (Lower)
  • Arm - Upper (Right)
  • Arm - Upper (Left)
  • Arm - Elbow (Right)
  • Arm - Elbow (Left)
  • Arm - Forearm (Right)
  • Arm - Forearm (Left)
  • Wrist (Right)
  • Wrist (Left)
  • Hand (Right)
  • Hand (Left)
  • Chest
  • Abdominal / Stomach
  • Groin / Anus
  • Leg - Upper (Right)
  • Leg - Upper (Left)
  • Leg - Knee (Right)
  • Leg - Knee (Left)
  • Leg - Lower (Right)
  • Leg - Lower (Left)
  • Ankle (Right)
  • Ankle (Left)
  • Foot (Right)
  • Foot (Left)
  • Shoulder (Left)
  • Shoulder (Right)
  • Other

• What was the cause of this injury or illness?

  Select Not Applicable Evidence Equipment Details Vehicle Details Damages Other Items

  • Not Applicable
  • Evidence
  • Equipment Details
  • Vehicle Details
  • Damages
  • Other Items

Person 3

• Is there another person involved?

  Yes

  No

• Full Name

• Contact phone number

• What is this person's relationship to the situation? (select all that apply)

  Select Reporter of incident Injured person Witness Primary person involved Secondary Involvement On-duty supervisor Investigator Suspect Other

  • Reporter of incident
  • Injured person
  • Witness
  • Primary person involved
  • Secondary Involvement
  • On-duty supervisor
  • Investigator
  • Suspect
  • Other

• Has this person sustained an injury?

  Yes

  No

Injury Details

• Type of injury or illness? (select all that apply)

  Select Not Applicable Superficial Open Wound Fatality Concussion Sprain Respiratory Eye Injury Burns Fracture Electrocution Fall Strain Dislocation Struck by object Entanglement Assault Muscle & Tendon Nerve & spinal cord Amputation Intracranial Other Injury

  • Not Applicable
  • Superficial
  • Open Wound
  • Fatality
  • Concussion
  • Sprain
  • Respiratory
  • Eye Injury
  • Burns
  • Fracture
  • Electrocution
  • Fall
  • Strain
  • Dislocation
  • Struck by object
  • Entanglement
  • Assault
  • Muscle & Tendon
  • Nerve & spinal cord
  • Amputation
  • Intracranial
  • Other Injury

• Parts of body affected? (select all that apply)

  Select Not Applicable General Ailment Head Eye (Left) Eye (Right) Ear Nose Throat Neck Back (Upper) Back (Lower) Arm - Upper (Right) Arm - Upper (Left) Arm - Elbow (Right) Arm - Elbow (Left) Arm - Forearm (Right) Arm - Forearm (Left) Wrist (Right) Wrist (Left) Hand (Right) Hand (Left) Chest Abdominal / Stomach Groin / Anus Leg - Upper (Right) Leg - Upper (Left) Leg - Knee (Right) Leg - Knee (Left) Leg - Lower (Right) Leg - Lower (Left) Ankle (Right) Ankle (Left) Foot (Right) Foot (Left) Shoulder (Left) Shoulder (Right) Other

  • Not Applicable
  • General Ailment
  • Head
  • Eye (Left)
  • Eye (Right)
  • Ear
  • Nose
  • Throat
  • Neck
  • Back (Upper)
  • Back (Lower)
  • Arm - Upper (Right)
  • Arm - Upper (Left)
  • Arm - Elbow (Right)
  • Arm - Elbow (Left)
  • Arm - Forearm (Right)
  • Arm - Forearm (Left)
  • Wrist (Right)
  • Wrist (Left)
  • Hand (Right)
  • Hand (Left)
  • Chest
  • Abdominal / Stomach
  • Groin / Anus
  • Leg - Upper (Right)
  • Leg - Upper (Left)
  • Leg - Knee (Right)
  • Leg - Knee (Left)
  • Leg - Lower (Right)
  • Leg - Lower (Left)
  • Ankle (Right)
  • Ankle (Left)
  • Foot (Right)
  • Foot (Left)
  • Shoulder (Left)
  • Shoulder (Right)
  • Other

• What was the cause of this injury or illness?

  Select

Accident Details

• What caused the accident?

  Select

• How did the accident occur? Describe what happened.

• What action did you take?

• Who did you advise of the accident?

  Select

• Does further action need to be taken?

  Yes

  No

• Who needs to take further action?

  Select

Near Miss Details

• Did a near miss occur?

  Yes

  No

• Describe how the near-miss occurred.

• What did you do about it?

• Who did you report it to?

  Select

• Did you advise other workers in the vicinity that the near-miss occurred?

  Yes

  No

• Who did you advise of the near-miss?

  Select

• What did you advise others to do?

Corrective Actions

• Are corrective/further actions required with regard to this incident?

  Yes

  No

• Please add any corrective actions to the appropriate questions above before completing this incident investigation

• Have all required corrective actions been added as Actions to this inspection?

  Yes

  No

  N/A

Root Cause Analysis / Contributing Factors

• What were the contributing factors to this incident occurring? (select all that apply)

  Select

• A Root Cause Analysis (RCA) is the process of determining the cause of an incident. It requires consideration of all the factors that may have contributed to this incident occurring and deeply understanding the underlying cause. One tactic to determine this is through asking "Why?" five times, to uncover the core of a problem.

• Has the root cause of this issue been able to be identified?

  Yes

  No

• Why is the root cause for this issue unable to be identified at this time?

• How likely is this incident to reoccur in future?

  Select

Sign Off

• Further action/follow-up/investigation required?

  Yes

  No

• Name of person/people to follow up

  Select

• Name of Reporter

  Select

• Name of Investigator(s) (may be different to the reporter).

  Select