BELWAY INCIDENT REPORT

• Conducted on

  Date

• Prepared by

• Location (site name, address & work area)

• Time of incident

  Date

A. What Kind of Incident Occured?

• INJURY

• Name of person injured:

• The injured person was a

  Customer

  Employee

  Contractor

  Guest

• Employee number:

• What treatment was provided?

  Select None required. First Aid (FAI) Ambulance (MTI) Doctor (MTI) Hospital Visit (MTI) Casualty (MTI) Overnight Stay (MTI)

  • None required.
  • First Aid (FAI)
  • Ambulance (MTI)
  • Doctor (MTI)
  • Hospital Visit (MTI)
  • Casualty (MTI)
  • Overnight Stay (MTI)

• Did the injured person return to work on the same day?

  Yes

  No

  N/A

• When did the injured person return to work?

  Date

• Select date

  Date

• The incident must be reported to WorkCover. You can phone in or report the incident online.

• Possible lost time injury

  Yes

  No

  N/A

• When did the injured person return to work?

  Date

• Are alternative duties required or has a RTW plan been provided for the injured worker? Please attached relevant documentation (medical certificates, RTW plan).

  Yes

  No

  N/A

• What duties can the injured person perform?

  No lifting

  Up to 5kg

  Up to 10kg

  Up to 4 hours standing

  Other - please specify:

• What caused the injury (statement by injured person)?

• Type of injury (cut, strain, heat stroke, crush injury etc):

• Part of body (finger, right hand, ankle, calf etc):

• Take photos of injury, cause of injury and work area.

  Media

• PROPERTY DAMAGE

• Describe what was damaged:

• Take photos of product, equipment and area around incident.

  Media

• Report damage to customer (full name of person reported to)

• NEAR MISS

• Describe what happened:

• When did the near miss occur?

  Date

• Take photos of the work area or where the near miss occurred.

  Media

B. Notification

• Has the customer been notified of the incident?

  Yes

  No

  N/A

• Who was the person representing the customer the incident was reported to (full name) ?

• NOTIFY THE CUSTOMER IMMEDIATELY: Provide the full name of person reported to.

C. INVESTIGATOR'S REPORT:

• Why did the incident occur? Give a full explanation of causes identified:

D. IMMEDIATE ACTIONS TAKEN:

• Detail steps take to prevent short term re-occurance:

E RECOMMENDATIONS FOR FURTHER ACTIONS:

• List additional steps or processes necessary for permanent correction:

F. SIGNATURES

• Person Involved in the incident:

• Add signature

  Sign

• Person reporting the incident: (if same as above, leave blank)

• Add signature

  Sign

• Person completing the incident report

• Add signature

  Sign

• Manager

• Add signature

  Sign

G. NOTES & IMAGES

• Please provide any additional notes:

• Please provide any additional images that may help with the investigation of the incident:

  Media