INCIDENT/INJURY REPORT FORM

• Type Of Incident/Injury Report Form

  Select Injury/Illness Employee Property Damage Contractor Hazard or Near Miss Guest/Visitor

  • Injury/Illness
  • Employee
  • Property Damage
  • Contractor
  • Hazard or Near Miss
  • Guest/Visitor

• Date Reported

  Date
• Sites
  Address

• Full Name

• Address
  Address

• Date of Birth

  Date

• Department

• Employment Status

  Full Time

  Part Time

  Casual

• Phone number

• Post Code

• Gender

  Female

  Male

• Position

• Company Name (If Contractor)-

• Date of the Incident

  Date

• Time of Incident

  Date

• Reported to

• Activity being performed at time of incident

• Exact location of incident
  Address

• Description of incident (full details including comments made by injured person)

• Has training been provided for this task?

  Yes

  No

• Name and contact details of witness/s

• Type of Injuries

  Select Sprain/Strain Laceration/Abrasion Bruising Fracture/dislocation Foreign Body Skin Irritation Crush Injury Dental Puncture Wound Soft Tissue Injury Other (Specify)

  • Sprain/Strain
  • Laceration/Abrasion
  • Bruising
  • Fracture/dislocation
  • Foreign Body
  • Skin Irritation
  • Crush Injury
  • Dental
  • Puncture Wound
  • Soft Tissue Injury
  • Other (Specify)

• Specify Other Injury:

• Yes

  No

• Identify Part of the Body Injured

  Select Left hand side Chest Abdomen Hip Leg Right Hand Side Groin Shoulder Elbow Finger (specify) Multiple Injuries Hand Wrist Arm (upper) Back (upper) Arm (lower) Head/face Nose Back (lower) Ears Foot Eyes Ankle Neck Knee Toe (specify) Other (Specify)

  • Left hand side
  • Chest
  • Abdomen
  • Hip
  • Leg
  • Right Hand Side
  • Groin
  • Shoulder
  • Elbow
  • Finger (specify)
  • Multiple Injuries
  • Hand
  • Wrist
  • Arm (upper)
  • Back (upper)
  • Arm (lower)
  • Head/face
  • Nose
  • Back (lower)
  • Ears
  • Foot
  • Eyes
  • Ankle
  • Neck
  • Knee
  • Toe (specify)
  • Other (Specify)

• Specific detail of the injury

• Specific Detail of the injury:

• Specify other injury:

• Was any treatment required?

  Select First Aid Went home Referred to Doctor Ambulance Sent to hospital Returned to work

  • First Aid
  • Went home
  • Referred to Doctor
  • Ambulance
  • Sent to hospital
  • Returned to work

• Treatment given

• Cause of the Accident

  Equipment

  Work Equipment

  Behavior

• Cause of Accident

  Select Poor maintenance Inadequate training Electrical / mechanical failure

  • Poor maintenance
  • Inadequate training
  • Electrical / mechanical failure

• Cause of Accident

  Select Accessibility Design / layout Other (specify): Machine design

  • Accessibility
  • Design / layout
  • Other (specify): Machine design

• Cause of Accident

  Poor Housekeeping

  Failure to follow procedures

  Speed / Short Cut / Fatigue

B. Assess The Risk

Hazard

• Hazard Description

• Exposure

  Very likely

  Likely

  Rare

  Very Rare

• Consequence

  Kill or disable

  Several Days off work

  First Aid

• High Risk Score

• High Risk Score

• Medium Risk Score

• Consequence

  Kill or disable

  Several Days off work

  First Aid

• High Risk Score

• Medium Risk Score

• Medium Risk Score

• Consequence

  Kill or disable

  Several Days off work

  First Aid

• Medium Risk Score

• Medium Risk Score

• Lower Risk Score

• Consequence

  Kill or disable

  Several Days off work

  First Aid

• Medium Risk Score

• Lower Risk Score

• Lower Risk Score

• Determine the Control Options

  Select Eliminate the Hazard Substitute the hazard (safer option) Modify the environment (change or redesign) Administrative control (training, signage etc) Personal protective equipment – PPE

  • Eliminate the Hazard
  • Substitute the hazard (safer option)
  • Modify the environment (change or redesign)
  • Administrative control (training, signage etc)
  • Personal protective equipment – PPE

• Short Term Control

• Long Term Control

• Who?

• When?

  Date

• Review?

Sign Off ((Manager or supervisor to sign when action required has been completed)

• Darren Bowley (Signature)

  Sign

• Report prepared by (Signature)

  Sign

• Position

• Name of person making report (injured or affected person) (Signature)

  Sign

• Other comments