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:

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