Title Page

  • Incident No.:

  • Audit relates to:

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

PART 1: INSTRUCTIONS

PART 1: INSTRUCTIONS

SECTION A: PERSONAL AND INCIDENT DETAILS

  • Full Name:

  • Date of Birth:

  • Are you? Relevant Worker / Contractor / Visitor

  • Gender:

  • Occupation:

  • Email address:

  • Phone (H):

  • Home address:
  • Date and time of incident:

  • Location of Incident:

  • How did the incident happen?

  • Signed:

  • Is there a Witness/es?

  • Name/s of Witness/es:

  • Phone:

Section B: SUPERVISOR or WORKSHOP MANAGER NOTIFICATION

  • WHS Manager Signed:

  • Phone:

  • Supervisor Signed:

  • 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:

  • Was medical treatment given?

  • Name of person giving initial treatment:

  • Date and time initial treatment given:

  • Time lost due to injury?

  • How many hours / days?

PART 2: INVESTIGATION CHECKLIST AND ACTION REPORT FORM

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?

  • Have you been instructed / trained in this task?

  • 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?

  • Please specify:

  • Type of Injury:

  • Please specify:

  • Safe Work Method Statements followed?

Identification of equipment/object/insect involved:

  • Equipment in good condition?

  • Date of last service of equipment:

  • Appropriate safety equipment (PPE) used?

  • Lighting adequate?

  • Housekeeping issues contributed?

  • Surface type:

  • Please specify:

  • Type of shoes worn:

  • Please specify:

  • Workload excessive?

  • Workload boring and repetitive?

  • Is it a slip or trip?

  • Height of fall / slip / trip by feet.

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

  • If stairs – going up / going down?

  • Which side did you fall?

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

  • Does the incident involves manual handling:

  • Were work items within easy reach?

  • Ergonomic equipment available?

  • Was the equipment being used correctly?

  • Repetitive and/or forceful movements used?

  • Action involved:

  • 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

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?

  • Action Required

  • By Whom

  • By When

Risk Control Options

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

  • Action Required

  • By Whom

  • By When

Risk Control Options

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

  • Action Required

  • By Whom

  • By When

Risk Control Options

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

  • Action Required

  • By Whom

  • By When

Risk Control Options

  • Is Personal Protective Equipment (PPE) Required?

  • Action Required

  • By Whom

  • By When

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

  • Signed:

  • Phone:

  • Position:

Office Use Only

  • Health and Safety Recommendations:

  • Date Part 2 received:

  • Date Completed:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.