Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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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
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First Name
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Last Name
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Contact Phone Number
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Position/Job Title
Incident/Injury/Hazard/Near Miss
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Description
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Date and Time of Incident
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Date and Time Reported
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Location Details
Incident Type
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What type of Incident are you Reporting?
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Was there any 3rd Party Damage, Environmental or Vehicle/Plant Damage?
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Description of damage caused
Injured/Ill Person Details
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Family Name
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Given Name(s)
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Date of Birth
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Gender
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Address
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Contact Number
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Occupation
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Supervisors Name
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Contact Number
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Employment Status
- Permanent
- Fixed Term
- Casual
- Contractor
- Part-Time
- Visitor
- Other
Incident Description
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Explain what Happened
Injury/Illness Details
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Injury Type
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Date and Time Duties Modified
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Treatment Type
- Medical Treatment
- Hospital
- First Aid
- Ambulance Called
- Intend to Seek Medical Treatment
- Work Cover Medical Certificate Issued
- No Treatment Required
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Description of Treatment Provided
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Treatment Provided By
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Contact Number
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Diagnosis of Injury/Illness
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Task being undertaken at time of injury/illness
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What part of the body was injured
Witness Details (if Applicable)
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Name
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Address
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Phone Number
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Add signature
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Date
WHAT HAPPENED? (Immediate Cause)
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Describe what happened
Possible Contributing Factors (select all that apply)
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Lack of Knowledge
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Employee Placement
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Not Enforcing Safe Work Practices
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Engineering
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Inadequate Personal Protective Equipment (PPE)
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Inadequate Maintenance Programs
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Purchasing Inadequate/Inferior Equipment
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Inadequate Feedback Systems
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Unsafe Work Method
Recommended Corrective Action Plan
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Basic Cause
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Corrective Action Plan
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Person Responsible
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Target Completion Date
Risk Assessment
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Consequences: Consider what did or Could have happened
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1=Death and Extensive Injuries, 2=Medical Treatment, 3=First Aid Treatment, 4=No Treatment
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Likelihood: How likely could this happen again
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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
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Risk Score
Applicants Details
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Name
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Position
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Contact Number
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Date Recorded
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Signature
Managers Details
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Name
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Position
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Contact Number
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Date Recorded
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Signature
Reporting
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LTI:
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MTI:
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Medical Certificate Required
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Workcover Notified