F.35.06.111 OH&S Incident/Hazard Report V.8.1

• Audit Title

Section A - Personal Details:

• Name:

• Surname:

• Job:

• Gender:

  Male

  Female

• Shift:

  AM

  PM

  Night

• Date of Birth:

  Date

Section B - Incident Category:

• Incident Category

  Select Employee Injury Visitor Injury Contractor Injury Environmental Damage Property Damage Near miss Maintenance Request (complete a F.35.06.29) Hazard Other

  • Employee Injury
  • Visitor Injury
  • Contractor Injury
  • Environmental Damage
  • Property Damage
  • Near miss
  • Maintenance Request (complete a F.35.06.29)
  • Hazard
  • Other
Tap to enter information

• Other (please specify)

Section C - Details of Incident

• Date and Time

  Date
• Location of incident:
  Address

• Type of injury:

  Select Sprain/Strain Bruising Laceration Facture Burn Other

  • Sprain/Strain
  • Bruising
  • Laceration
  • Facture
  • Burn
  • Other
Tap to enter information

• Other (please specify)

• Part of Body

  Select Head Eye Neck Arm Chest Abdomen Back Leg Foot/Toes Hand/Fingers Systemic

  • Head
  • Eye
  • Neck
  • Arm
  • Chest
  • Abdomen
  • Back
  • Leg
  • Foot/Toes
  • Hand/Fingers
  • Systemic

• Cause of injury/illness

  Select Struck by Struck Against Caught on Caught between/in Fall Radiation Over exertion Electricity Chemicals/Gas Flash Heat Other

  • Struck by
  • Struck Against
  • Caught on
  • Caught between/in
  • Fall
  • Radiation
  • Over exertion
  • Electricity
  • Chemicals/Gas
  • Flash
  • Heat
  • Other
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• Other (please specify)

• Hazard

  Select Manual Handling Noise Lighting Weather Extreme/Over Exertion Mechanical/Electrical Chemical/Gas Biological/Environment Risk of fire or Explosion Work surfaces (floors/Benches) Dust Trip Hazard Other

  • Manual Handling
  • Noise
  • Lighting
  • Weather Extreme/Over Exertion
  • Mechanical/Electrical
  • Chemical/Gas
  • Biological/Environment
  • Risk of fire or Explosion
  • Work surfaces (floors/Benches)
  • Dust
  • Trip Hazard
  • Other
Tap to enter information

• Other (please specify)

Section D - Description of Incident/Hazard

• To be completed by the injured employee or reporter of the hazard. In the case of a serious incident, this must be completed by the injured employees supervisor.

• Description of Incident/Hazard

Section E - Supervisor Comments

• Supervisor Comments

Section F - Incident Investigation

• Is further information required?

  Yes

  No

• Is the investigation report completed?

  Yes

  No
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• Name of the Investigator

• Date of the investigation

  Date

• Cost of the Maintenance completed

• PO Number

Section G - Non-Conformance

• Is a non-conformance report required?

  Yes

  No
Tap to enter information

• Date report completed?

  Date

Section H - Signatures

• Injured person/Person reporting hazard

  Sign

• Employees Manager/OH&S Manager

  Sign

• PLEASE NOTE: Once completed this form must be sent to the organisations OH&S officer and filed as per the records maintenance procedure.