INCIDENT / INJURY REPORT FORM - local copy

• Incident No.:

• Audit relates to:

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

PART 1: INSTRUCTIONS

SECTION A: PERSONAL AND INCIDENT DETAILS

• Full Name:

• Date of Birth:

  Date

• Are you? Relevant Worker / Contractor / Visitor

  Relevant Worker

  Contractor

  Visitor

• Gender:

  Male

  Female

• Occupation:

• Email address:

• Phone (H):

• Home address:
  Address

• Date and time of incident:

  Date

• Location of Incident:

• How did the incident happen?

• Signed:

  Sign

• Is there a Witness/es?

  Yes

  None

  N/A

• Name/s of Witness/es:

• Phone:

Section B: SUPERVISOR or WORKSHOP MANAGER NOTIFICATION

• WHS Manager Signed:

  Sign

• Phone:

• Supervisor Signed:

  Sign

• Phone:

Section C: INJURY DETAILS (If applicable) Use this section to also report workplace disease.

• Type of injury or disease (e.g. burn)

• Part/s of the body affected:

• Date and time when symptoms noticed:

  Date

• Was medical treatment given?

  No

  First Aid

  Nurse

  Doctor

  Hospital

• Name of person giving initial treatment:

• Date and time initial treatment given:

  Date

• Time lost due to injury?

  Yes

  No

  N/A

• How many hours / days?

PART 2: INVESTIGATION CHECKLIST AND ACTION REPORT FORM

• Incident / Injury: How do you think the incident / injury happened and what were you doing at the time?

Investigation Checklist:

• How long had you been working prior to the incident / injury?

• How long had you been working on this task?

• Is this task part of your normal duties?

  Yes

  No

  N/A

• Have you been instructed / trained in this task?

  Yes

  No

  N/A

• What were you doing in the time prior to the incident / injury?

• Are there any other factors involved (e.g. management, equipment, maintenance, individual)?

• Any other comments or observations?

Please answer / highlight the most appropriate response/s:

• What sort of incident / injury occurred?

  Select Manual Handling Occupational Overuse Syndromes Cuts Bruises Burns Falls Slips Trips Vehicles Bicycles Hazardous Substances Insects Animals Foreign Body Plant Stress Others

  • Manual Handling
  • Occupational Overuse Syndromes
  • Cuts
  • Bruises
  • Burns
  • Falls
  • Slips
  • Trips
  • Vehicles
  • Bicycles
  • Hazardous Substances
  • Insects
  • Animals
  • Foreign Body
  • Plant
  • Stress
  • Others

• Please specify:

• Type of Injury:

  Select Sting Bite Kick Puncture Strain Sprain Hazardous Substance Slip Trip Fall Other

  • Sting
  • Bite
  • Kick
  • Puncture
  • Strain
  • Sprain
  • Hazardous Substance
  • Slip
  • Trip
  • Fall
  • Other

• Please specify:

• Safe Work Method Statements followed?

  Yes

  No

  N/A

Identification of equipment/object/insect involved:

• Equipment in good condition?

  Yes

  No

  N/A

• Date of last service of equipment:

  Date

• Appropriate safety equipment (PPE) used?

  Yes

  No

  N/A

• Lighting adequate?

  Yes

  No

  N/A

• Housekeeping issues contributed?

  Yes

  No

  N/A

• Surface type:

  Select Cement Tile Grass Dry Wet Damaged Torn Sand Footpath Carpet Gravel Rocks Road Other

  • Cement
  • Tile
  • Grass
  • Dry
  • Wet
  • Damaged
  • Torn
  • Sand
  • Footpath
  • Carpet
  • Gravel
  • Rocks
  • Road
  • Other

• Please specify:

• Type of shoes worn:

  Select Open Closed Boots High Heels Sandals None Other

  • Open
  • Closed
  • Boots
  • High Heels
  • Sandals
  • None
  • Other

• Please specify:

• Workload excessive?

  Yes

  No

  N/A

• Workload boring and repetitive?

  Yes

  No

  N/A

• Is it a slip or trip?

  Yes

  No

  N/A

• Height of fall / slip / trip by feet.

• Were you running / walking / turning a corner / jumping / other?

• If stairs – going up / going down?

  going up

  going down

• Which side did you fall?

  Front

  Back

  Side

• What were you carrying (if anything) at the time?

• Does the incident involves manual handling:

  Yes

  No

  N/A

• Were work items within easy reach?

  Yes

  No

  N/A

• Ergonomic equipment available?

  Yes

  No

  N/A

• Was the equipment being used correctly?

  Yes

  No

  N/A

• Repetitive and/or forceful movements used?

  Yes

  No

  N/A

• Action involved:

  Select Reaching Bending Stooping Sitting Kneeling Twisting Pushing Pulling Lifting Catching Lowering Carrying

  • Reaching
  • Bending
  • Stooping
  • Sitting
  • Kneeling
  • Twisting
  • Pushing
  • Pulling
  • Lifting
  • Catching
  • Lowering
  • Carrying

• Weight of object by lbs.

• Distance carried / position of object moved from / to?

• Height of load by feet?

PART 3: TO BE COMPLETED BY WHS MANAGER

• Investigator’s comments and observations from part 2:

• This is the most important part of the investigation process! Do not leave blank.

Risk Control Options

• Elimination – do you have to do the task?

  Yes

  No

  N/A

• Action Required

• By Whom

• By When

Risk Control Options

• Substitution – is there another way you can do the task?

  Yes

  No

  N/A

• Action Required

• By Whom

• By When

Risk Control Options

• Engineering – can you engineer a way to make the job safer?

  Yes

  No

  N/A

• Action Required

• By Whom

• By When

Risk Control Options

• Administration – can you improve work practices? E.g. limit time of exposure.

  Yes

  No

  N/A

• Action Required

• By Whom

• By When

Risk Control Options

• Is Personal Protective Equipment (PPE) Required?

  Yes

  No

  N/A

• Action Required

• By Whom

• By When

• Date feedback provided to person reporting the injury/incident:

  Date

• Signed:

  Sign

• Phone:

• Position:

Office Use Only

• Health and Safety Recommendations:

• Date Part 2 received:

  Date

• Date Completed:

  Date