Information
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Client / Site
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Prepared by
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Conducted on
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Document No.
Section 1
THIS DOCUMENT IS SPLIT INTO 5 SECTIONS. TOOGLE THROUGH THE SECTIONS AT THE BOTTOM OF THE PAGE.
SECTION 1 - Accident/Incident Type
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Select either 'Personal', Event' or 'Near Hit'
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PERSONAL (non work related injury)
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EVENT - Accident/incident resulting in injury, illness, damage or harm.
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DAMAGE TO PLANT OR EQUIPMENT
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Select Type
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ENVIRONMENTAL
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Select Type
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Please specify
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NEAR HIT - An incident that had the potential in resulting in injury, illness, damage or harm.
NOTE: For 'Near Hit' complete investigation in relation to potential outcome of incident.
Initial Report Status
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First Aid
Revised Status (if revised)
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Medically Treated Injury
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Lost Time Injury
Once complete email copies of this to Senior Management and Safety Department.
Section 2
THIS DOCUMENT IS SPLIT INTO 5 SECTIONS. TOOGLE THROUGH THE SECTIONS AT THE BOTTOM OF THE PAGE.
SECTION 2 - Incident Details
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Date and Time of Accident/Incident
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Date and Time of Investigation Report
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Person(s) Carrying Out Investigation
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Contractor
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Contract Persons' Drivers Licence
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Location of Accident/Incident
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Activity at Time of Accident/Incident
Person(s) Involved
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Full Name of Employee(s)
Employee
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Full Name
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Supervisor
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Safety Advisor/Representative
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Any Witnesses
Witness
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Witness Name
What Happened/What Was Observed
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Please only state factual information.
Examples: What is the damage or loss - What was the injured party doing - What had the injured party been instructed to do - What tools were being used - What did the injured/witness see - What safety rules were violated - What safety procedures were in place - What permits were being used - What isolation procedures were in place - What training had been given - What communication system was in place at the time -
Employee Statement Form
Statement
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Statement
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Name and Signature
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Witness
Once complete email copies of this to Senior Management and Safety Department.
Section 3
THIS DOCUMENT IS SPLIT INTO 5 SECTIONS. TOOGLE THROUGH THE SECTIONS AT THE BOTTOM OF THE PAGE.
SECTION 3 - Injury Details
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Nature of Injury - select at least one
- Amputation
- Burn
- Concussion
- Contusion/Crush
- Dermatitis
- Dislocation
- Disorder of Muscle, Tendon (soft tissue)
- Foreign Body
- Fracture
- Internal Injury
- Laceration/Open Wound
- Superficial Injury
- Sprain/Strain
- Other, none specified
- No injury
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Please specify
Select body location (see diagram for reference)
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Body Location of Injury - select at least one
- Back
- Ear
- Eye
- Face
- Feet and Toes
- Hand/Finger
- Head (other than eye, ear, face)
- Hip/Leg
- Internal Organs
- Neck
- Shoulder and Arms
- Trunk (excluding internal organs)
- Other
- No injury
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Please specify
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Front of Body
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Right Side
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Left Side
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Rear of Body
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Right Side
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Left Side
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Body Diagram
Once complete email copies of this to Senior Management and Safety Department.
Section 4
THIS DOCUMENT IS SPLIT INTO 5 SECTIONS. TOOGLE THROUGH THE SECTIONS AT THE BOTTOM OF THE PAGE.
SECTION 4 - Contributing Factors Analysis
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Injury Agency - select at least one
- Chemicals
- Live Animals
- Machinery and Fixed Plant
- Mobile Plant
- Non Powered Tools
- Outdoor Environment
- Power Equipment, Tools, etc.
- Road Transport
- Unspecified Agencies
- No Unsafe Actions/Activities
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Please specify
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Mechanism of Injury - select at least one
- Contact with Electricity
- Exposure to Mechanical Vibration
- Falls From Heights
- Falls From Same Level
- Hit by Moving Object
- Hitting Objects With Part of Body
- Inadequate/insufficient Tools
- Repetitive Movement with Low Muscle Loading
- Single Contact with Chemical Substance
- Vehicle Accident
- Other
- No Unsafe Pant or Equipment Factors
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Please specify
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Environmental Factors - select at least one
- Close Clearance or Poor Access
- Difficult/Unsafe Traffic Conditions
- Lighting
- Natural Features
- Poor Storage/Housekeeping
- Weather Conditions
- Other
- No Unsafe Environmental Factors
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Please specify
Once complete email copies of this to Senior Management and Safety Department.
Section 5
THIS DOCUMENT IS SPLIT INTO 5 SECTIONS. TOOGLE THROUGH THE SECTIONS AT THE BOTTOM OF THE PAGE.
SECTION 5 - Root Causes Analysis
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Determining Root Cause
It's section of the investigation helps to enter mine the route cause using the '5 Why' process.
The '5 Why' process is a simple problem-solving technique that helps users to get to the root problem quickly, a strategy which involves looking at any problem and asking: 'Why?' and 'What caused the problem?'
How to Use the Tool
When looking to solve a problem, start at the end result and work backward (towards the root cause), continually asking 'Why?' This will need to be repeated over and over until the root cause of the problem becomes apparent. -
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Start here by writing down the specific problem
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Main Cause Determined After Investigation
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After this investigation, what changes have been made to prevent re-occurrence
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Training To Be Carried Out
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Please specify training required
- Induction
- Task Specific
- Specialised
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Is an Action Plan to be raised as a result of the investigation
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Investigation Sign Off - Senior Manager
