Cromwell Incident and Investigation Report Form

• Client / Site

• Conducted on

  Date

• Prepared/Approved by

• Location
  Address

PART A – Details of Injured/Involved Person

• Full Name (Surname, Given Name)

• Address
  Address

• Date of Birth

  Date

• Job Title

• Basis of Employment

  Visitor

  Contractor

  Customer

  Client

  Other

• •Specify

PART B – Details of Incident

• Details of Incidents

  Near Miss

  Incident with Injury/Illness

  Dangerous Incident

  Notifiable incident

  Property Damage

• Name of person completing this report

• Position

• Description of Incident

• Date of incident

  Date

• Date reported

  Date

• Name/position of person incident reported to

• Name(s) and Contact Number(s) of any witnesses

•Witness

• Full Name and Contact Number

• Treatment Provided

  Select None First Aid Doctor Ambulance Hospital Other (specify)

  • None
  • First Aid
  • Doctor
  • Ambulance
  • Hospital
  • Other (specify)

• •Specify

• •Name of treatment provider

• •Hospital

• Witness Report taken and on file?

  Yes

  No

• •EDMS #

• Photos taken of injured party or damaged property and area of incident?

  Yes

  No

• Is a worker’s compensation claim likely to be made?

  Yes

  No

• •Have claim forms been completed and enclosed?)

  Yes

  No

• Is this a notifiable incident?

  Yes

  No

• 

• Was weather conditions a contributing factor to the Incident?

  Yes

  No

• Select all injured Body Part(s)

  Select Head Neck Shoulder Lower Back Hand Wrist Finger Elbow Knee Ankle Foot Lower Arm Upper Arm Lower Leg Upper Leg Multiple Other

  • Head
  • Neck
  • Shoulder
  • Lower Back
  • Hand
  • Wrist
  • Finger
  • Elbow
  • Knee
  • Ankle
  • Foot
  • Lower Arm
  • Upper Arm
  • Lower Leg
  • Upper Leg
  • Multiple
  • Other

• List all Other Injured Body parts

•Body Part

• •Specify

• Select all Injury Type

  Select Fracture / Dislocation Sprain / Strain Multiple Injuries Poisoning & toxic effects of substances. Burn Foreign Body (on external eye, in ear or nose) Open wound (graze / cut) Head Injury Stress Claim Internal Injury Traumatic Amputation Contusion (bruising) Other

  • Fracture / Dislocation
  • Sprain / Strain
  • Multiple Injuries
  • Poisoning & toxic effects of substances.
  • Burn
  • Foreign Body (on external eye, in ear or nose)
  • Open wound (graze / cut)
  • Head Injury
  • Stress Claim
  • Internal Injury
  • Traumatic Amputation
  • Contusion (bruising)
  • Other

• List all Other Injury Types

•Injury

• •Specify

• Select all Mechanism of Injury

  Select Plant / Equipment Hit by Moving Object Material/Chemical/Substance Slip / Trip / Fall Laceration Human Error System of Work Fall from Height Manual Handling Fatigue Electrical Other

  • Plant / Equipment
  • Hit by Moving Object
  • Material/Chemical/Substance
  • Slip / Trip / Fall
  • Laceration
  • Human Error
  • System of Work
  • Fall from Height
  • Manual Handling
  • Fatigue
  • Electrical
  • Other

• List all Other Mechanism of Injury

•Mechanism of Injury

• •Specify

• Work Location
  Address

• New or recurring injury

• Date and Time of Injury/incident

  Date
• Location of injury/incident
  Address

• Weather Condition

• First Aid given

• Photos and/or CCTV footage collected & filed EDMS#

• Upload relevant photos as needed

  Media

PART C – Details of Incident

• Describe the sequence of events that led to the incident happening

• Describe the sequence of events following the incident

• Describe the task being performed at the time of the incident

• Treating Doctors Name

• Name(s) and Signature(s) of people rendering first aid

•First Aider

• Full Name and Signature

  Sign

• Equipment involved

• Was the person trained to do the task

  Yes

  No

• Time the employee held the position

  Date

• Has the person stopped work

  Yes

  No

• Signature of injured employee

  Sign

• Signature of injured workers' Manager

  Sign

PART D – Incident Risk Rating

• Using the Risk Matrix
  - Rate the consequence (severity) of the incident
  - Rate the likelihood of the incident occurring or re-occurring
  

• •Risk Matrix

  

• Resultant risk rating on the matrix

  Very High

  High

  Medium

  Low

  Very Low

PART E – Contributing Factors

•Unsafe Acts

• Improper work technique

  ✔

  ✖

• Safety rule violation

  ✔

  ✖

• Improper PPE or PPE not used

  ✔

  ✖

• Operating without authority

  ✔

  ✖

• Failure to warn or secure

  ✔

  ✖

• Operating at improper speeds

  ✔

  ✖

• By-passing safety devices

  ✔

  ✖

• Guards not used

  ✔

  ✖

• Improper loading or placement

  ✔

  ✖

• Improper lifting

  ✔

  ✖

• Servicing machinery in motion

  ✔

  ✖

• Horseplay

  ✔

  ✖

• Drug or alcohol use

  ✔

  ✖

• Unnecessary haste

  ✔

  ✖

• Unsafe act of others

  ✔

  ✖

•Unsafe Conditions

• Poor workstation design/layout

  ✔

  ✖

• Congested work area

  ✔

  ✖

• Hazardous substances

  ✔

  ✖

• Fire or explosion hazard

  ✔

  ✖

• Inadequate ventilation

  ✔

  ✖

• Improper material storage

  ✔

  ✖

• Improper tool or equipment

  ✔

  ✖

• Insufficient knowledge of job

  ✔

  ✖

• Slippery conditions

  ✔

  ✖

• Poor housekeeping

  ✔

  ✖

• Excessive noise

  ✔

  ✖

• Inadequate guarding of hazards

  ✔

  ✖

• Defective tools/equipment

  ✔

  ✖

• Insufficient lighting

  ✔

  ✖

• Inadequate fall protection

  ✔

  ✖

•System/Management Deficiencies

• Lack of written procedures or policies

  ✔

  ✖

• Safety rules not enforced

  ✔

  ✖

• Hazards not identified

  ✔

  ✖

• PPE unavailable

  ✔

  ✖

• Insufficient worker training

  ✔

  ✖

• Insufficient supervisor training

  ✔

  ✖

• Improper maintenance

  ✔

  ✖

• Inadequate supervision

  ✔

  ✖

• Inadequate job planning

  ✔

  ✖

• Inadequate hiring practices

  ✔

  ✖

• Inadequate workplace inspection

  ✔

  ✖

• Inadequate equipment

  ✔

  ✖

• Unsafe design or construction

  ✔

  ✖

• Unrealistic scheduling

  ✔

  ✖

• Poor process design

  ✔

  ✖

•Incident Analysis

• Using the root-cause analysis list above, explain the cause(s) of the incident in as much detail as possible.

PART F – Corrective Action and Close Out

• Action Taken/Recommended (in accordance with the hierarchy of controls)
  Click on +Add Action to set due date and assign to specific person

•Action Taken

• Details

PART G – Corrective Action - Residual Risk Rating

• Using the Risk Matrix
  - Rate the consequence (severity) of the incident following the completion of Corrective Actions
  - Rate the likelihood of the incident re-occurring

• •RIsk Matrix

  

• Resultant risk rating on the matrix

  Very High

  High

  Medium

  Low

  Very Low

Completion and Incident Closed out

• Full Name(s) and Signature(s) of person involved on Incident Closed out

•Person

• Full Name and Signature

  Sign

• Position

• Prepared/Approved By: (Full Name and Signature)

  Sign