Incident, Injury, Near Miss, Environmental Report Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• This form must be completed for an incident involving injury/illness or reporting a workplace hazard or near miss involving property and/or environmental damage. Incidents involving actual or potential significant injury/illness must be reported immediately to management.

Person Completing the Form

• First Name

• Last Name

• Contact Phone Number

• Position/Job Title

Incident/Injury/Hazard/Near Miss

• Description

  Incident

  Hazard

  Injury

  Near Miss

• Date and Time of Incident

  Date

• Date and Time Reported

  Date

• Location Details

Incident Type

• What type of Incident are you Reporting?

  Injury/Illness

  Hazard

  Near Miss

  Vehicle

• Was there any 3rd Party Damage, Environmental or Vehicle/Plant Damage?

  3rd Party Property Damage

  Environmental Damage

  Vehicle/Plant Damage

• Description of damage caused

Injured/Ill Person Details

• Family Name

• Given Name(s)

• Date of Birth

• Gender

  Male

  Female

• Address

• Contact Number

• Occupation

• Supervisors Name

• Contact Number

• Employment Status

  Select Permanent Fixed Term Casual Contractor Part-Time Visitor Other

  • Permanent
  • Fixed Term
  • Casual
  • Contractor
  • Part-Time
  • Visitor
  • Other

Incident Description

• Explain what Happened

Injury/Illness Details

• Injury Type

  Lost Time Injury

  Modified Duties Injury

  Light Duties Injury

• Date and Time Duties Modified

  Date

• Treatment Type

  Select Medical Treatment Hospital First Aid Ambulance Called Intend to Seek Medical Treatment Work Cover Medical Certificate Issued No Treatment Required

  • Medical Treatment
  • Hospital
  • First Aid
  • Ambulance Called
  • Intend to Seek Medical Treatment
  • Work Cover Medical Certificate Issued
  • No Treatment Required

• Description of Treatment Provided

• Treatment Provided By

• Contact Number

• Diagnosis of Injury/Illness

• Task being undertaken at time of injury/illness

• What part of the body was injured

Witness Details (if Applicable)

• Name

• Address

• Phone Number

• Add signature

  Sign

• Date

  Date

WHAT HAPPENED? (Immediate Cause)

• Describe what happened

Possible Contributing Factors (select all that apply)

• Lack of Knowledge

  Yes

  No

  N/A

• Employee Placement

  Yes

  No

  N/A

• Not Enforcing Safe Work Practices

  Yes

  No

  N/A

• Engineering

  Yes

  No

  N/A

• Inadequate Personal Protective Equipment (PPE)

  Yes

  No

  N/A

• Inadequate Maintenance Programs

  Yes

  No

  N/A

• Purchasing Inadequate/Inferior Equipment

  Yes

  No

  N/A

• Inadequate Feedback Systems

  Yes

  No

  N/A

• Unsafe Work Method

  Yes

  No

  N/A

Recommended Corrective Action Plan

• Basic Cause

• Corrective Action Plan

• Person Responsible

• Target Completion Date

  Date

Risk Assessment

• Consequences: Consider what did or Could have happened

  1

  2

  3

  4

• 1=Death and Extensive Injuries, 2=Medical Treatment, 3=First Aid Treatment, 4=No Treatment

• Likelihood: How likely could this happen again

  A

  B

  C

  D

• A=Could Occur in Most Instances, B=Could Occur at Some Time, C=Could Occur, but only Rarely, D=May Occur, but Probably never will

• Risk Score

  High

  Medium

  Low

Applicants Details

• Name

• Position

• Contact Number

• Date Recorded

  Date

• Signature

  Sign

Managers Details

• Name

• Position

• Contact Number

• Date Recorded

  Date

• Signature

  Sign

Reporting

• LTI:

  Yes

  No

  N/A

• MTI:

  Yes

  No

  N/A

• Medical Certificate Required

  Yes

  No

  N/A

• Workcover Notified

  Yes

  No

  N/A