Information
-
Prepared by
-
Site
-
Personnel
-
Conducted on
Person Details
-
Name:
-
Address:
-
Phone Number:
-
Date of Birth:
-
Sex:
Employment Details
-
Job Title:
-
Employment Status:
Accident/Incident Details
-
Date: and Time
-
Weather conditions:
-
Hours at work:
-
Date Reported:
-
Accident type:
-
Accidents results in Human Injury
AL = Accident Lost Time
ANL = Accident No Lost Time
Near Miss is all incidents that result in damage to equipment/material, as well as those incidents were damage or injury was avoided.
NM = Near Miss
NF = Notifiable Event (see Worksafe Notifiable Event Info Cards) report to Worksafe as soon as practicable ph: 0800 030 040 -
Treatment Given:
-
Was the Person Hospitalised
-
Has worksafe been notified
-
Notify Worksafe 0800 030 040
-
Nature of Injury:
- No Injury
- Cut
- Gradual Process
- Bruising
- Sprain/Strain
- Burns
- Poison/Chemical
- Fracture/Break
- Head Injury
- Multiple Injuries
-
Injury Location Chart
-
Injury Location
-
Where did the accident happen? Eg. Office / Skid / Road
-
How did the accident happen?
-
Was the person trained for the task they were doing?
-
If a vehicle was involved record type or vehicle / rego
-
Was a significant hazard involved?
-
What was the significant Hazard?
-
How serious could the injuries have been?
Steps to prevent similar event happening again
-
Specific Action Required:
-
Person Responsible:
-
By When:
-
Date Completed:
-
Initial needs assessment (only complete if Doctor visit was required)
- Able to continue full duties
- Able to do light duties
- Unable to Work
- Help available at home
- Assistance required at home
- Transport assistance needed
-
Form completed by:
Add signature:
-
Signature:
