Employee Incident Report and Investigation Form - duplicate

• Incident Report & Investigation Form

• Store Location

  Blacktown

  Crossroads

  Auburn

• Type of Incident

  Employee - Full Time

  Employee - Part Time

  Employee - Casual

• Document No.

• Conducted on

  Date

Reporting Details

• Name of Person reporting the incident

• Manager Name & Contact Number

  Select Khalil Abbas - Retail Operations Manager 0428 746 253 Shaun Austen - Warehouse Operations Manager 0424 808 581 Venkat Yenerni - Store Manager Crossroads 9083 6501 Mark Mleczko - Store Manager - Blacktown 0448 478 066 Anglela Hili - Administration Manager Blacktown 0405 219 939 Ben Woods - Zone A Manager Blacktown 0405 219 939 Debbie Contzonis - Furniture Supervisor Crossroads 0407 273 416 Leyon Fereti - Flooring Supervisor Blacktown0402 247 249 Craig Fisher - Warehouse Supervisor Blacktown 0431 454 868 Kim Chamberlain - VM Manager 0409 257 413 Jethro David - Zone B Manager Blacktown 0429 067 360 Dinesh Sharma - Customer Service Supervisor Blacktown - 0451 531 660

  • Khalil Abbas - Retail Operations Manager 0428 746 253
  • Shaun Austen - Warehouse Operations Manager 0424 808 581
  • Venkat Yenerni - Store Manager Crossroads 9083 6501
  • Mark Mleczko - Store Manager - Blacktown 0448 478 066
  • Anglela Hili - Administration Manager Blacktown 0405 219 939
  • Ben Woods - Zone A Manager Blacktown 0405 219 939
  • Debbie Contzonis - Furniture Supervisor Crossroads 0407 273 416
  • Leyon Fereti - Flooring Supervisor Blacktown0402 247 249
  • Craig Fisher - Warehouse Supervisor Blacktown 0431 454 868
  • Kim Chamberlain - VM Manager 0409 257 413
  • Jethro David - Zone B Manager Blacktown 0429 067 360
  • Dinesh Sharma - Customer Service Supervisor Blacktown - 0451 531 660

• Report Type

  Employee - Full Time

  Employee - Casual

  Employee - Part time

Injured Person Details

• First Name

• Surname

• Date of Birth (dd/mm/yyyy)

• Sex

  Male

  Female

• Home Address

• Contact Number

• Which department do they work.

  Select Homewares Flooring Customer Service Furniture Bedding Kitchens Appliances Warehouse Support Visual Merchandising Not Applicable - Customer Not Applicable - Contractor Other

  • Homewares
  • Flooring
  • Customer Service
  • Furniture
  • Bedding
  • Kitchens
  • Appliances
  • Warehouse
  • Support
  • Visual Merchandising
  • Not Applicable - Customer
  • Not Applicable - Contractor
  • Other

Occupation/Job Title & Details

• Position Held

  Select Manager Supervisor Cafe Customer Service Salesperson Storeman Support Office VM Assistant

  • Manager
  • Supervisor
  • Cafe
  • Customer Service
  • Salesperson
  • Storeman
  • Support Office
  • VM Assistant

• Employment Type

  Permanent Fulltime

  Permanent Part time

  Casual

  Contractor

  Not Applicable - Customer - Go to Incident Details

• Usual Hours

• Normal hours of work

  Fixed Shift

  Rotating Shift

• Training/Qualifications Held

  Induction

  Task Specific

  Trade

  Professional

  None

Incident Details

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• Task at time of incident

• To whom was the incident reported?

• Where did this occur?

  Select Homewares Flooring Customer Service Furniture Bedding Kitchens Appliances Warehouse Support Visual Merchandising Not Applicable - Customer Not Applicable - Contractor Other

  • Homewares
  • Flooring
  • Customer Service
  • Furniture
  • Bedding
  • Kitchens
  • Appliances
  • Warehouse
  • Support
  • Visual Merchandising
  • Not Applicable - Customer
  • Not Applicable - Contractor
  • Other

• Description of the incident/what happened

• Photo's of injury or Incident scene

  Media

• Add sketches (if needed)

  Drawing

• Are there any witness(es)? If yes, provide name(s) and contact phone numbers

  Yes

  No

  N/A

• If yes - Enter details here

• If this incident was a result of a Product, enter the I0 number, description and take a photo

• Take photo of product

  Media

DETAILS OF INJURY, IF APPLICABLE

• Was the worker required to cease work (eg stop work for the day) or likely to cease work?

  Yes

  No

  N/A

• Injury/Illness

  Select Bruise, graze, scratch Amputation Anxiety/stress Asphyxia Back pain Bump/blow Burn/scald Broken bones(s)/fracture Dislocation (without fracture) Cut/laceration Puncture/penetration injury Foreign body Crush injury Chemical burn Electric shock/burn Effects of smoke Fatal Injury Hernia Loss of sight (temp or perm.) Sprain/strain Other injury No apparent injury Unknown N/A

  • Bruise, graze, scratch
  • Amputation
  • Anxiety/stress
  • Asphyxia
  • Back pain
  • Bump/blow
  • Burn/scald
  • Broken bones(s)/fracture
  • Dislocation (without fracture)
  • Cut/laceration
  • Puncture/penetration injury
  • Foreign body
  • Crush injury
  • Chemical burn
  • Electric shock/burn
  • Effects of smoke
  • Fatal Injury
  • Hernia
  • Loss of sight (temp or perm.)
  • Sprain/strain
  • Other injury
  • No apparent injury
  • Unknown
  • N/A

• Side of Body

  Left

  Right

  N/A

• Severity of Injury

  Select No Treatment (and return to work) First Aid (and return to work) Professional Medical Treatment Required Restricted Work Absence from Work Major Injury (eg broken bones) Fatal

  • No Treatment (and return to work)
  • First Aid (and return to work)
  • Professional Medical Treatment Required
  • Restricted Work
  • Absence from Work
  • Major Injury (eg broken bones)
  • Fatal

• Part of Body - Select more than one if required

  Select Abdomen Ankle Arm Back Calf Chest Ear Elbow Eye Face Finger Foot Groin Hand Head Hip Internal Knee Leg Neck Lung Mouth Shoulder Thigh Toes Wrist N/A

  • Abdomen
  • Ankle
  • Arm
  • Back
  • Calf
  • Chest
  • Ear
  • Elbow
  • Eye
  • Face
  • Finger
  • Foot
  • Groin
  • Hand
  • Head
  • Hip
  • Internal
  • Knee
  • Leg
  • Neck
  • Lung
  • Mouth
  • Shoulder
  • Thigh
  • Toes
  • Wrist
  • N/A

• Area

  Select Upper Lower Inner Outer Cheek Chin Forehead Jaw Nose Thumb Index finger Middle figits Sole Big toe Little toe Back of Hand Palm of Hand Front Back Lips Inside mouth Teeth Unknown N/A

  • Upper
  • Lower
  • Inner
  • Outer
  • Cheek
  • Chin
  • Forehead
  • Jaw
  • Nose
  • Thumb
  • Index finger
  • Middle figits
  • Sole
  • Big toe
  • Little toe
  • Back of Hand
  • Palm of Hand
  • Front
  • Back
  • Lips
  • Inside mouth
  • Teeth
  • Unknown
  • N/A

TREATMENT

• Was treatment given

  Select No treatment given Treatment offered but refused Yes, at scene Yes, at local first aid point Yes, at local GP surgery Yes, at hospital

  • No treatment given
  • Treatment offered but refused
  • Yes, at scene
  • Yes, at local first aid point
  • Yes, at local GP surgery
  • Yes, at hospital

• When was treatment given?

  Date

• Who provided the treatment

  First Aider

  Doctor

  Bystanders

  Customer

  Other

• Detail any first-aid or medical treatment administered. (Provide names)

• Nature of treatment

• What happened after initial treatment?

  Select Return to Work Resumed normal activities Sent or taken to hospital Referred to Local GP (workcover) Referred to hospital Referred to own GP Sent or taken home Other Not known

  • Return to Work
  • Resumed normal activities
  • Sent or taken to hospital
  • Referred to Local GP (workcover)
  • Referred to hospital
  • Referred to own GP
  • Sent or taken home
  • Other
  • Not known

INVESTIGATION (to be conducted by Manager in consultation with relevant employee's)

• Why did this occur?

Hazard Identification and Risk Assessment information

• What hazards have you identified?

• What could have potentially happened?

• Likelihood (How likely is it to happen?)

  Almost Certain

  Likely

  Possible

  Unlikely

  Rare

• Consequence (How bad is it likely to be)

  Insignificant

  Minor

  Moderate

  Major

  Severe

• Risk matrix

  

• Name of Investigator

• If not previously identified, enter the hazard and control implemented, onto the Risk register and allocate the same reference number for both forms for ease of cross referencing. If not effective, a Hazard Report Form is to be completed.

• Using the Risk matrix, establish your rating

  VH - Immediate Action is required

  H - Important to do something about this hazard as soon as possible

  M - Risk control measures as required

  L - Manage by routine procedures

Hazard Control Strategy

• Consider more than one control. the last two controls being the least effective

  Select Elimination Substitution Isolation Engineering Administrative PPE (Personal Protective Equipment)

  • Elimination
  • Substitution
  • Isolation
  • Engineering
  • Administrative
  • PPE (Personal Protective Equipment)

• If controlled immediately, list details here.

• If longer term controls are required, list details here

• Date to be implemented

  Date

• Does the Manager believe that this hazard should be communicated with all employees?

  Yes

  No

  N/A

• If yes, how will this be communicated?

  Email

  Formal Team meeting

  Urgent informal team meeting

  Information on workplace noticeboard

  Other

• Date report completed

  Date

• Manager confirms that consultation has been completed

  Sign

• Date

  Date

• Employee representative verifies consultation has been complete

  Sign

• Date

  Date

• Send this completed form within 24hrs of incident to injury@wngroup.com.au and your Store Manager