Incident Report

• Conducted on

  Date

• Prepared by

• Location
  Address

• Who?

  Select Contractor / Service Provider Member of Public / Visitor

  • Contractor / Service Provider
  • Member of Public / Visitor

• Full home Address of person(s) affected

• Occurrence Date & Time

  Date

• Reported Date & Time

  Date

• Full name of person(s) affected

• Contact phone number(s)

• D.O.B

  Date

• Occupation

• Occupation details (Business name, address)

• Location of incident at the center

• Event Classification

  Select Near Miss Incident Hazard Community Contact HSE Document / Contract Issue

  • Near Miss
  • Incident
  • Hazard
  • Community Contact
  • HSE Document / Contract Issue

• Brief description on incident

• Immediate action taken

• Injury Type

  Select Fracture Dislocation Sprain & Strain Superficial injury Open wound Foreign body on external eye, ear, nose, respiratory system Burns Suspected poisoning Effects of weather, exposure and/or other external causes Multiple injuries Other

  • Fracture
  • Dislocation
  • Sprain & Strain
  • Superficial injury
  • Open wound
  • Foreign body on external eye, ear, nose, respiratory system
  • Burns
  • Suspected poisoning
  • Effects of weather, exposure and/or other external causes
  • Multiple injuries
  • Other

• Injury/illness Consequence

  Select Lost time Medical Treatment First Aid No Treatment Non Work Related

  • Lost time
  • Medical Treatment
  • First Aid
  • No Treatment
  • Non Work Related

• Bodily location and injury / disease description

• Image of injury

  Media

• Mechanism of Injury/ disease

  Select Fall from heights Trips & slips Hitting objects with body Being hit by moving object Repetitive movement Other muscle stress Contact with electricity Heat or cold exposure Radiation exposure Single contact with chemical or substance Biological exposure Mental stress exposure Slide or cave in Vehicle accident Other or multiple mechanisms of injury Unspecified

  • Fall from heights
  • Trips & slips
  • Hitting objects with body
  • Being hit by moving object
  • Repetitive movement
  • Other muscle stress
  • Contact with electricity
  • Heat or cold exposure
  • Radiation exposure
  • Single contact with chemical or substance
  • Biological exposure
  • Mental stress exposure
  • Slide or cave in
  • Vehicle accident
  • Other or multiple mechanisms of injury
  • Unspecified

• Breakdown agency/& agency of injury/disease

  Select Machinery & fixed plant Mobile plant Road transport Other transport Powered equipment, tools & appliances Non-powered hand tools Non-powered equipment Chemicals Non-metallic substances Other materials, substances or objects Outdoor environment Indoor enviroment Live animals Non-live animals Human agencies Biological agencies Non-physical agencies Other agencies

  • Machinery & fixed plant
  • Mobile plant
  • Road transport
  • Other transport
  • Powered equipment, tools & appliances
  • Non-powered hand tools
  • Non-powered equipment
  • Chemicals
  • Non-metallic substances
  • Other materials, substances or objects
  • Outdoor environment
  • Indoor enviroment
  • Live animals
  • Non-live animals
  • Human agencies
  • Biological agencies
  • Non-physical agencies
  • Other agencies

• What did you see and observe?

• Was there a third party involved? ie: Did a cleaner attend?<br>If yes, please attach a third party incident report. <br>

  Yes

  No

• Was there any property damage? If 'yes' please describe damage, location of damage and add image

  yes

  no

• Did any anyone attend to the affected person? If 'yes', who?

  yes

  no

• Was First Aid treatment administered at the workplace?If 'Yes' who?

  Yes

  No

• Please provide details of the injury/ illness and First Aid treatment provided:

• Medical Center/ Doctor/ Hospital that the injured person attended

• Did an ambulance attend? If 'Yes' who requested the ambulance?

  Yes

  No

Person completing incident report

• Name

• Select date

  Date

Complete this section ONLY IF THE AFFECTED PERSON IS A MEMBER OF THE PUBLIC

• Was the weather a factor? If 'Yes' add brief description

  Yes

  No

• Did this person appear to be affected by drugs or alcohol? If 'Yes' add brief description

  Yes

  No

• Type of footwear worn?

• Were they carrying anything? If 'Yes' add brief description

  Yes

  No

• CCTV available?

  Yes

  No

• Photos available?

  Yes

  No

• Wand reports available?

  Yes

  No

• Warning signs present?

  Yes

  No

• Wet weather mats installed?

  Yes

  No

• Any additional comments?

At the time of the incident was the affected person:

• Using crutches

• Using a walking stick

• Using a walking frame

• Using a wheelchair

• Using a motorised wheelchair/ scooter

• Please ensure the following is included with all incident reports
  Photos (not just screen shots of footage)
  CCTV footage – 30 minutes before and prior to the incident
  Third party incident reports
  Witness statements