Aqua Metro Services Incident / Injury Report Form

• Reported on

  Date

• Reported by

• Client / Site

• Location of incident
  Address

Personal and Incident Details

• Name of person making report

• Contact number

• Email address

• Incident description - what happened?

• Incident with injury

  Incident without injury

Injury Details

• Injured person's name

• Position

• Date of birth

• Type of injury?

  Select Abrasion Allergic reaction Bite Break Bruise Burn Cut / contusion Puncture Sprain Sting Strain Other

  • Abrasion
  • Allergic reaction
  • Bite
  • Break
  • Bruise
  • Burn
  • Cut / contusion
  • Puncture
  • Sprain
  • Sting
  • Strain
  • Other

• Part/s of the body affected

• Date and Time of symptoms

  Date

• Injury cause?

  Select Manual tasks Lifting operations Slips / trips / falls Struck by Caught in/between/under Electricity Dropped object(s) Foreign body Lack of ventilation Inhalation / respiration Fire / hot surface Hazardous Substances Biological Insects/Animals Temperature extremes Vibration Psychosocial eg Stress, fatigue Radiation Noise Other

  • Manual tasks
  • Lifting operations
  • Slips / trips / falls
  • Struck by
  • Caught in/between/under
  • Electricity
  • Dropped object(s)
  • Foreign body
  • Lack of ventilation
  • Inhalation / respiration
  • Fire / hot surface
  • Hazardous Substances
  • Biological
  • Insects/Animals
  • Temperature extremes
  • Vibration
  • Psychosocial eg Stress, fatigue
  • Radiation
  • Noise
  • Other

• Was medical treatment given?

  Yes

  No

  N/A

• What treatment was provided?

• Where / by whom (multiple selection)?

  Select Self-treated First Aider Doctor Nurse At work Medical Centre Hospital Other

  • Self-treated
  • First Aider
  • Doctor
  • Nurse
  • At work
  • Medical Centre
  • Hospital
  • Other

• Date and Time of treatment

  Date

• Details of treatment provider

• Time lost due to injury?

  Yes

  No

  N/A

• How many hours/days?

• Is it a slip, trip or fall?

  Yes

  No

• Height of fall (m)

• Were you -

  Select Running Walking Turning a corner Jumping Down a slope Up a slope

  • Running
  • Walking
  • Turning a corner
  • Jumping
  • Down a slope
  • Up a slope

• If stairs -

  Going up

  Going down

  N/A

• Did you fall on your -

  Back

  Front

  Side

• What were you carrying (if anything) at that time?

• Surface type

  Select Cement Tile Grass Sand Footpath Carpet Gravel Rocks Road Dry Wet Torn Damaged Other

  • Cement
  • Tile
  • Grass
  • Sand
  • Footpath
  • Carpet
  • Gravel
  • Rocks
  • Road
  • Dry
  • Wet
  • Torn
  • Damaged
  • Other

• Type of shoes worn

  Select Safety boots Open Closed High Heels Sandals None Other

  • Safety boots
  • Open
  • Closed
  • High Heels
  • Sandals
  • None
  • Other

• Were there any other parties / witnesses involved?

  Yes

  No

  N/A

• Name and phone number of any witness(es) * Name, address, phone number and licence details of other party/parties if vehicle incident

• Does it involve manual handling?

  Yes

  No

• Were your items within easy reach?

  Yes

  No

  N/A

• Safety equipment available?

  Yes

  No

  N/A

• Was the equipment being used correctly?

  Yes

  No

  N/A

• Repititive and forceful movements used?

  Yes

  No

• Action involved

  Select Lifting Pushing Reaching Pulling Carrying Bending Stooping Sitting Kneeling Twisting Catching Lowering Squatting

  • Lifting
  • Pushing
  • Reaching
  • Pulling
  • Carrying
  • Bending
  • Stooping
  • Sitting
  • Kneeling
  • Twisting
  • Catching
  • Lowering
  • Squatting

• Weight of object (kg)

• Distance carried/position of object moved from/to (m)

• Height of load (m)

Incident details

• At fault?

  Yes

  No

• Were there any other parties / witnesses involved?

  Yes

  No

  N/A

• Name and phone number of any witness(es) * Name, address, phone number and licence details of other party/parties if vehicle incident

• What immediate action(s) were taken?

• Are any further actions required?

  Yes

  No

  N/A

• Note further actions required eg repairs, clean-up etc

Vehicle / plant / property

• Equipment/vehicles/plant/property involved?

  Yes

  No

• Description of damage

• Previous condition of vehicle / plant / property

  Good

  Fair

  Poor

• $ Cost estimate of damage

• Condition after incident

  Good

  Fair

  Poor

Investigation

• What were you doing prior to the incident?

• How long had you been working? (hours)

• Is this task part of your normal duties?

  Yes

  No

  N/A

• Have you been trained for this task?

  Yes

  No

  N/A

• Safe Work Method Statements followed?

  Yes

  No

  N/A

• Appropriate safety equipment used?

  Yes

  No

  N/A

• Lighting adequate?

  Yes

  No

  N/A

• Housekeeping issues contributed?

  Yes

  No

• Was the workload:

  Select Excessive? Boring? Repetitive? Unsafe?

  • Excessive?
  • Boring?
  • Repetitive?
  • Unsafe?

• Are there any other factors involved (e.g work environment, equipment, management)?

Report completion

• Recommendation

  Select Elimination of the task Substition or another way of doing the task Engineer a way to make the job safer Administration, signage or improve work practices Personal Protective Equipment

  • Elimination of the task
  • Substition or another way of doing the task
  • Engineer a way to make the job safer
  • Administration, signage or improve work practices
  • Personal Protective Equipment

• Details

• Person assigned

• Target Date

  Date

• Signature

  Sign