Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
SECTION 1: DETAILS OF INCIDENT
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Date of Report and Time of Report:
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Date of Incident and Time of Incident
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Full Name of the Worker
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Exact Location of Incident:
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Describe how/why the Incident Occurred: The employee and/or witness states the following.
Was there any witnesses?
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Witnesses 1: Full Name
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What was the witnesses doing at the time & what was observed?
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Witnesses 2: Full Name
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What was the witnesses doing at the time & what was observed?
SECTION 2: Details of Reporting Person & Position
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Name of person reporting the Incident and his position?
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Reporting person explanation of what took place.
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What immediate action took place to prevent danger to other worker. Describe Action
SECTION 3: SUPERVISOR's/MANAGER's INVESTIGATION DETAILS (Attach photographs/sketches where relevant) [CONSIDER WHETHER LEGAL PRIVILEGE SHOULD BE OBTAINED BEFORE COMPLETING THIS SECTION]
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State the specific task/activity at time of incident:
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Pictures of job site area:
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Describe what task/activity the injured person was doing immediately before the incident:
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Was the incident site inspected following the incident?
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Do you think this is a notifiable incident under the SA WHS ACT 2012?
CONTRIBUTING FACTORS (Events and conditions that contributed to the incident)
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Was the design, construction or use of plant/equipment a contributing factor?
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Was a hazardous condition such as working environment, or the location of tools, equipment or materials, a contributing factor?
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Was the management system that governed the above task and function defective?
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Did personal/human factors influence the behaviour/actions of the individual?
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Was the work method being performed a contributing factor?
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Was lack of personal protective equipment a contributing factor?
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Investigated By:
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Investigator's Signature:
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Date / Time
SECTION 4: CORRECTIVE ACTION Explain what is required so that the problems that have been identified can be eliminated or effectively controlled.
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1) Eliminate:
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2) Replace / Substitute:
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3) Redesign:
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4) Administrative Controls (i.e. safe operating procedures, PPE):
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5) Where required, has a risk assessment been conducted (i.e. plant safety, manual handling)?
PERSON(S) RESPONSIBLE FOR COMPLETING CORRECTIVE ACTION:
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Supervisor Signature & Name:
SECTION 5): HEALTH & SAFETY MANAGER COMMENTS:
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Comments:
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Name & Signature:
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Select date
