FLSL Incident/Accident/Near Miss Form

• Prepared by

• Site

• Personnel

• Conducted on

  Date

Person Details

• Name:

• Address:

• Phone Number:

• Date of Birth:

• Sex:

  Male

  Female

Employment Details

• Job Title:

• Employment Status:

  Permanent

  Casual

  Contractor

  Visitor

Accident/Incident Details

• Date: and Time

  Date

• Weather conditions:

• Hours at work:

• Date Reported:

  Date

• Accident type:

  Near Miss

  Accident Lost Time

  Accident No Lost Time

• 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:

  No Treatment

  First Aid

  Doctor

  Hospital

  Serious Harm

• Was the Person Hospitalised

  No

  Yes

• Has worksafe been notified

  No

  Yes

• Notify Worksafe 0800 030 040

  No

  Yes

• Nature of Injury:

  Select No Injury Cut Gradual Process Bruising Sprain/Strain Burns Poison/Chemical Fracture/Break Head Injury Multiple Injuries

  • 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?

  Yes

  No

  N/A

• If a vehicle was involved record type or vehicle / rego

• Was a significant hazard involved?

  No

  Yes

• 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

• Date Completed:

  Date

• Initial needs assessment (only complete if Doctor visit was required)

  Select Able to continue full duties Able to do light duties Unable to Work Help available at home Assistance required at home Transport assistance needed

  • 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:

  Injured Worker

  Immediate Supervisor

  Management

  Treating Doctor
Add signature:

• Signature:

  Sign