INCIDENT & INVESTIGATION REPORT

• Business:

  Select

• Date of Incident:

  Date

• Time of Incident:

• Incident Report Completed by:

• (SYSTEMS MANAGER USE ONLY) Status of Report:

  COMPLETED

  PENDING

• Incident / Event has been documented in the Incident Register

• What issues / actions are pending?

INCIDENT DETAILS

• Where did the incident occur? (include the addess and the specific location, for example; next to the greenhouse adjacent to garden)

• What type of Event occurred?

  Select Fatality Dangerous Event Injury Work Caused Illness Bullying / Harassment Electrical Incident Environmental Incident Near Miss Property / Equipment / Vehicle Damage Other

  • Fatality
  • Dangerous Event
  • Injury
  • Work Caused Illness
  • Bullying / Harassment
  • Electrical Incident
  • Environmental Incident
  • Near Miss
  • Property / Equipment / Vehicle Damage
  • Other

• Fatalities are a Notifiable Event under the Work Health & Safety Act, refer to the following for more details: https://www.worksafe.qld.gov.au/injury-prevention-safety/incidents-and-notifications/what-is-an-incident

• Date and Time the relevant department was notified:

  Date

DETAILS OF PERSON FATALLY INJURED

• Deceased Persons Relationship to The Real Group

  Select Employee Apprentice / Trainee Visitor / Student Member of the Public Contractor Other

  • Employee
  • Apprentice / Trainee
  • Visitor / Student
  • Member of the Public
  • Contractor
  • Other

• Provide Details:

• Name:

• Date of Birth:

  Date

• Address:

DETAILS OF INCIDENT THAT LEAD TO THE FATALITY

• Describe the circumstances that caused the fatality (i.e. crush injury, break, fall, impact):

• Provide a detailed description of how the injury occurred including details of any plant or equipment that was being used at the time:

• Immediate Actions (what was immediately done to preserve the incident site):

• Serious Injuries may be a Notifiable Event in accordance with the Work Health and Safety Act, consult your manager and refer to the following for more details: https://www.worksafe.qld.gov.au/injury-prevention-safety/incidents-and-notifications/what-is-an-incident#incident

• Is the Injury a Notifiable Event in accordance with the Work Health and Safety Act?

  Yes

  No

• Date and Time the relevant department was notified:

  Date

DETAILS OF INJURED PERSON

• Injured Persons Relationship to The Real Group

  Select Employee Apprentice / Trainee Visitor / Student Member of the Public Contractor Other

  • Employee
  • Apprentice / Trainee
  • Visitor / Student
  • Member of the Public
  • Contractor
  • Other

• Name:

• Date of Birth:

  Date

• Phone number:

• Address:

• Was treatment required after the event?

  Yes

  No

• What type of treatment was necessary?

  First Aid Treatment (FAI)

  Medical Treatment (MTI)

• Provide details of medical treatment (i.e. what, where, who by):

• Provide details:

INJURY DETAILS

• Describe the Injury (i.e. fracture, strain, bruise, dislocation):

• Body Location (i.e. head, left arm, lower back, right ankle):

• Provide a detailed description of how the injury occurred including details of any plant or equipment that was being used at the time:

• A Dangerous Event may be a Notifiable Event under the Work Health & Safety Act, consult your manager and refer to the following for more details: https://www.worksafe.qld.gov.au/injury-prevention-safety/incidents-and-notifications/what-is-an-incident

• Is the Dangerous Event a Notifiable Event in accordance with the Work Health and Safety Act?

  Yes

  No

• Date and Time the relevant department was notified:

  Date

DETAILS OF DANGEROUS EVENT

• Describe the Dangerous Event (include as much detail as possible. i.e. the events that led to the dangerous event; the work being undertaken when the dangerous event occurred; the event that best describes the circumstances that resulted in the dangerous event:

• Were any people involved in the Dangerous Event?

  Yes

  No
Details of Person/s Involved:

• Name:

• Contact Number:

• Was any person injured as a result of the Dangerous Event?

  Yes

  No

DETAILS OF INJURED PERSON/S

Injured Person

• Name:

• Injured Persons Relationship to The Real Group

  Select Employee Apprentice / Trainee Visitor / Student Member of the Public Contractor Other

  • Employee
  • Apprentice / Trainee
  • Visitor / Student
  • Member of the Public
  • Contractor
  • Other

• Provide details:

• Date of Birth:

  Date

• Phone number:

• Address:

• Was medical treatment required after the event?

  Yes

  No

• Provide details of medical treatment (i.e. what, where, who by):

INJURY DETAILS

• Describe the Injury (i.e. fracture, strain, bruise, dislocation):

• Body Location (i.e. head, left arm, lower back, right ankle):

• Provide a detailed description of how the injury occurred including details of any plant or equipment that was being used at the time:

• Immediate Actions (what was immediately done to stop the incident from getting worse and / or to preserve the incident site):

EVIDENCE AND WITNESS DETAILS

• What evidence has been collected or provided?

  Select Written Statements Verbal Statement Photos Procedures Maintenance Records Witness Other

  • Written Statements
  • Verbal Statement
  • Photos
  • Procedures
  • Maintenance Records
  • Witness
  • Other

• Provide details:

• Attach photos:

  Media

• Was there a witness to the incident?

  Yes

  No

• Name of Witness:

• Witness detail of events:

• Witness Signature:

  Sign

• Work caused illnesses may be a Notifiable Event in accordance with the Work Health and Safety Act, consult your manager and refer to the following for more details: https://www.worksafe.qld.gov.au/injury-prevention-safety/incidents-and-notifications/what-is-an-incident#incident

• Is the Illness a Notifiable Event in accordance with the Work Health and Safety Act?

  Yes

  No

• Date and Time the relevant department was notified:

  Date
DETAILS OF ILL PERSON/S

• Ill Persons Relationship to The Real Group

  Select Employee Apprentice / Trainee Visitor / Student Member of the Public Contractor Other

  • Employee
  • Apprentice / Trainee
  • Visitor / Student
  • Member of the Public
  • Contractor
  • Other

• Provide details:

• Name:

• Date of Birth:

  Date

• Phone number:

• Address:

• Has the ill person received medical treatment?

  Yes

  No

• Provide details of medical treatment (i.e. what, where, who by):

DETAIL OF EVENTS THAT LED TO THE PERSON BECOMING ILL

• Describe the type of symptoms the ill person was exhibiting (i.e. vomiting, fainting, seizure)

• Describe the type of work the ill person was doing at the time of becoming unwell (i.e. mowing the lawn, spraying weeds)

• Provide a detailed description of how the person became ill including details of any chemicals, substances, plant or equipment that was being used at the time:

• Electrical Incidents may be a Notifiable Event in accordance with the Work Health and Safety Act, consult your manager and refer to the following for more details: https://www.worksafe.qld.gov.au/injury-prevention-safety/incidents-and-notifications/what-is-an-incident#incident

• Is the Electrical Incident a Notifiable Event in accordance with the Work Health and Safety Act?

  Yes

  No

• Date and Time the relevant department was notified:

  Date

DETAILS OF ELECTRICAL INCIDENT

• Describe the Electrical Incident (include as much detail as possible. i.e. the events that led to the incident; the work being undertaken when the incident occurred; the event that best describes the circumstances that resulted in the electrical incident):

• Were any people involved in the Electrical Incident?

  Yes

  No
Details of Person/s Involved:

• Name:

• Contact Number:

• Was any person injured as a result of the Electrical Incident?

  Yes

  No

DETAILS OF INJURED PERSON

Injured Person

• Name:

• Injured Persons Relationship to The Real Group

  Select Employee Apprentice / Trainee Visitor / Student Member of the Public Contractor Other

  • Employee
  • Apprentice / Trainee
  • Visitor / Student
  • Member of the Public
  • Contractor
  • Other

• Provide details:

• Date of Birth:

  Date

• Phone number:

• Was medical treatment required after the event?

  Yes

  No

• Provide details of medical treatment (i.e. what, where, who by):

INJURY DETAILS

• Describe the Injury (i.e. fracture, strain, bruise, dislocation):

• Body Location (i.e. head, left arm, lower back, right ankle):

• Provide a detailed description of how the injury occurred including details of any plant or equipment that was being used at the time:

• Environmental Incidents may be a Notifiable Event in accordance with the Environmental Protection Act, consult your manager and refer to the following for more details: https://environment.des.qld.gov.au/management/compliance-enforcement/obligations-duties

• Is the Environmental Incident a Notifiable Event in accordance with the Environmental Protection Act?

  Yes

  No

• Date and Time the relevant Department was notified?

  Date

• Has the environmental incident been contained?

  Yes

  No

  Part

• Ensure the incident is contained to the best of your ability to minimise the impact

DETAILS OF ENVIRONMENTAL INCIDENT

• Describe the Environmental Incident (include as much detail as possible. i.e. the events that led to the incident; the work being undertaken when the incident occurred; the event that best describes the circumstances that resulted in the environmental incident):

• Were any people involved in the Environmental Incident?

  Yes

  No
Details of Person/s Involved:

• Name:

• Contact Number:

• Was any person/s injured as a result of the Environmental Incident?

  Yes

  No

DETAILS OF INJURED PERSON

Injured Person:

• Name:

• Injured Persons Relationship to The Real Group

  Select Employee Apprentice / Trainee Visitor / Student Member of the Public Contractor Other

  • Employee
  • Apprentice / Trainee
  • Visitor / Student
  • Member of the Public
  • Contractor
  • Other

• Provide details:

• Date of Birth:

  Date

• Phone number:

• Was medical treatment required after the event?

  Yes

  No

• Provide details of medical treatment (i.e. what, where, who by):

INJURY DETAILS

• Describe the Injury (i.e. fracture, strain, bruise, dislocation):

• Body Location (i.e. head, left arm, lower back, right ankle):

• Provide a detailed description of how the injury occurred including details of any plant or equipment that was being used at the time:

ENVIRONMENTAL DETAILS (if applicable)

• Provide details of the Environmental Incident (type of spill; wildlife / vegetation disturbance; pollution; nuisance; quantity / volume of material escaped or causing incident):

• Describe the exact Location of Incident (include landmarks, features, watercourses):

• Provide any additional details (activity being undertaken when the incident occurred; immediate environmental response actions taken if applicable):

• This incident may be a Notifiable Event under the Work Health & Safety Act, consult your manager and refer to the following for more details: https://www.worksafe.qld.gov.au/injury-prevention-safety/incidents-and-notifications/what-is-an-incident

• Is the Near Miss a Notifiable Event in accordance with the Work Health and Safety Act?

  Yes

  No

• Date and Time the relevant department was notified:

  Date

DETAILS OF NEAR MISS

• Describe the Near Miss (include as much detail as possible. i.e. the events that led to the near miss; the work being undertaken when the near miss occurred; the event that best describes the circumstances that resulted in the near miss:

• Were any people involved in the Near Miss?

  Yes

  No
Details of Person/s Involved:

• Name:

• Contact Number:

DETAILS OF PROPERTY / EQUIPMENT / VEHICLE DAMAGE

• Provide a detailed account of the incident. Include the events leading up to the incident; the work being undertaken when the damage occurred; the event that best describes the circumstances that resulted in the damage:

• Were any people involved in the Property / Equipment / Vehicle Damage Incident? (Injured or not injured)

  Yes

  No
Details of Person/s Involved:

• Name:

• Contact Number:

• Was the person injured as a result of the Property / Equipment / Vehicle Damage Incident?

  Yes

  No

DETAILS OF INJURED PERSON

Injured Person

• Name:

• Injured Persons Relationship to The Real Group

  Select Employee Apprentice / Trainee Visitor / Student Member of the Public Contractor Other

  • Employee
  • Apprentice / Trainee
  • Visitor / Student
  • Member of the Public
  • Contractor
  • Other

• Provide details:

• Name:

• Date of Birth:

  Date

• Phone number:

• Was medical treatment required after the event?

  Yes

  No

• Provide details of medical treatment (i.e. what, where, who by):

• Provide details of medical treatment (i.e. what, where, who by):

INJURY DETAILS

• Describe the Injury (i.e. fracture, strain, bruise, dislocation):

• Body Location (i.e. head, left arm, lower back, right ankle):

• Provide a detailed description of how the injury occurred including details of any plant or equipment that was being used at the time:

EQUIPMENT / PROPERTY DETAILS

• Describe the vehicle / equipment / property i.e. make, model, registration number

• Describe the exact location of where the incident occurred

• Describe the damage caused

DETAILS OF THE MISCELLANEOUS EVENT / INJURY

• Describe the event / incident (include as much detail as possible. i.e. the details of the event that best describes the circumstances that resulted in the incident):

• Were any people involved in the Event / Incident?

  Yes

  No
Details of Person/s Involved:

• Name:

• Contact Number:

• Was any person injured as a result of the Event / Injury?

  Yes

  No

DETAILS OF INJURED PERSON

Injured Person

• Name:

• Injured Persons Relationship to The Real Group

  Select Employee Apprentice / Trainee Visitor / Student Member of the Public Contractor Other

  • Employee
  • Apprentice / Trainee
  • Visitor / Student
  • Member of the Public
  • Contractor
  • Other

• Provide details:

• Date of Birth:

  Date

• Phone number:

• Date of Birth:

  Date

• Phone number:

• Was medical treatment required after the event?

  Yes

  No

• Provide details of medical treatment (i.e. what, where, who by):

• Provide details of medical treatment (i.e. what, where, who by):

INJURY DETAILS

• Describe the Injury (i.e. fracture, strain, bruise, dislocation):

• Body Location (i.e. head, left arm, lower back, right ankle):

• Provide a detailed description of how the injury occurred including details of any plant or equipment that was being used at the time:

EVIDENCE AND WITNESS DETAILS

• What evidence has been collected or provided?

  Select Written Statements Verbal Statement Photos Procedures Maintenance Records Witness Other

  • Written Statements
  • Verbal Statement
  • Photos
  • Procedures
  • Maintenance Records
  • Witness
  • Other

• Witness Statement:

Witness/s Details

• Name of Witness:

• Witness detail of events:

• Attach photos:

  Media
Statement Details:

• Name of Person providing the statement:

• What procedures were referred to?

• Attach relevant procedures:

  Media

• Attach maintenance records:

  Media

ACKNOWLEDGEMENT

• Signature of Person Providing the Incident Details:

  Sign

• Signature of Operations Manager:

  Sign

MANAGEMENT NOTIFICATION

• Have all the above questions been answered and the relevant people signed the acknowledgement?

  Yes

  No

INVESTIGATION TO BE COMPLETED IN CONSULATION WITH THE QSE DEPARTMENT

INVESTIGATION PLAN

• What immediately cause the incident or event to occur?

• What are the suspected root causes (prior to undertaking any investigation)?

• Are there any other noteworthy observations?

IF THIS INCIDENT IS A NOTIFIABLE OR HIGH POTENTIAL INCIDENT A DETAILED INVESTIGATION IS REQUIRED

• Does this incident categorise as a 'Notifiable' or 'High Potential Incident'? (Please select)

  Select A fatality An accident causing immediate admission to hospital as an inpatient (a person presenting to the emergency department for treatment is not considered an 'inpatient') An accident causing an injury that has the potential to cause permenant injury to health An uncontrolled escape or ignition of gas or steam An electric shock to a person An uncontrolled fire on a building, vehicle, plant, equipment or appliance An uncontrolled escape, spillage or spillage or leakage of a hazardous substance A fall or release from height The overturning of any plant or vehicle Other or Investigation Determined by CEO or Authorised Representative No, this incident does not categorise as a 'Notifiable' or 'High Potential Incident'

  • A fatality
  • An accident causing immediate admission to hospital as an inpatient (a person presenting to the emergency department for treatment is not considered an 'inpatient')
  • An accident causing an injury that has the potential to cause permenant injury to health
  • An uncontrolled escape or ignition of gas or steam
  • An electric shock to a person
  • An uncontrolled fire on a building, vehicle, plant, equipment or appliance
  • An uncontrolled escape, spillage or spillage or leakage of a hazardous substance
  • A fall or release from height
  • The overturning of any plant or vehicle
  • Other or Investigation Determined by CEO or Authorised Representative
  • No, this incident does not categorise as a 'Notifiable' or 'High Potential Incident'

INVESTIGATION TO BE COMPLETED IN CONSULATION WITH THE QSE DEPARTMENT

Investigation Team Members:

• Name:

• Position Title:

Investigation Objectives:

• Goal:

• Responsible Person:

• Investigation Scope (boundaries of the investigation)

• What date is the investigation expected to be completed by?

  Date

• Are there any constraints to meet the investigation timeframe?

PEEPO (People, Environment, Equipment, Procedure, Organisation )

People:

• Name:

• Involvement in Incident / Investigation

Environment:

• Location of Event:

• Has the scene been secured / preserved and photos / measurements taken?

  Yes

  Part

  No

  N/A

• Environmental Factors influencing the event: (consider weather, lighting, area set up, housekeeping, dust, water etc)

Equipment:

• Was plant or equipment involved in the incident / event?

  Yes

  No
Equipment Involved

• Type of Equipment:

• Were prestarts conducted for the plant / equipment involved? (if yes, attach as evidence)

  Yes

  Part

  No

  N/A

• Did the prestarts reveal any faults?

  Yes

  No

• Provide details:

• Equipment factors that may influence the event: (consider equipment selected for task / design / modifications / age / condition)

Procedures:

• Was there a procedure for the task?

  Yes

  No

  Part

• List the names of the procedures:

• Was there a risk assessment completed for the task?

  Yes

  No

• Were the hazards that resulted in the incident identified in either the procedure/s or risk assessment/s

  Yes

  Part

  No

  N/A

• What were the controls?

• Was the procedure or risk assessment followed for the task?

  Yes

  Part

  No

  N/A

• Specify the procedural / risk assessment step/s that weren't followed

Organisation:

• Were there previous related or similar incidents involving the team and / or persons involved in the event?

  Yes

  No
Previous Incident

• Specific details:

• What is the status of actions from previous incidents? (if applicable)

EVALUATE INFORMATION / ANALYSIS

• Contributing Factors:

• Root Cause:

• Additional Findings:

IDENTIFIED COURSES OF ACTION

Summary of Corrective Actions Identified during Investigation

• Identified Action

• Process to communicate completed action

  Select Toolbox Talks Email Newsletter Hub Meeting/s Employee Induction Other N/A

  • Toolbox Talks
  • Email
  • Newsletter
  • Hub Meeting/s
  • Employee Induction
  • Other
  • N/A

• How will the process / findings be communicated to the workgroup?

• Responsible Person to Communicate Findings

• Reason for not doing a detailed investigation:

Sign Off:

• Systems Manager (or Authorised Representative) sign off:

  Sign