Incident Report - Foott

• Details of the Person Reporting the Event or Hazard

• Conducted on

  Date

• Location of Event or Hazard

• Type of Event

  Select Incident - Something did occur and harm was caused Hazard - Something could occur Near Miss - Something did occur but there was no harm

  • Incident - Something did occur and harm was caused
  • Hazard - Something could occur
  • Near Miss - Something did occur but there was no harm

• NOTE:
  This general template can be used for all incidents, however it is important to check with your state regulatory body requirements and/or Insurer as to the legal reporting requirements. You can modify this template to suit your workplace needs.

Incident Details

• Date and time of incident

  Date

• Classification of Incident

  Select Injury Environmental Motor Vehicle Damage Fleet Damage (Truck) Property Customer Premises Report Only

  • Injury
  • Environmental
  • Motor Vehicle Damage
  • Fleet Damage (Truck)
  • Property
  • Customer Premises
  • Report Only

• Were there any injuries?

  Yes

  No

• Type of injury

  Select Amputation Bruise/Abrasion Burn Crush Dislocation Fatigue/Stress Foreign Body Fracture Illness Laceration/Puncture Strain/Strain Other

  • Amputation
  • Bruise/Abrasion
  • Burn
  • Crush
  • Dislocation
  • Fatigue/Stress
  • Foreign Body
  • Fracture
  • Illness
  • Laceration/Puncture
  • Strain/Strain
  • Other

• Immediate Cause

  Select Chemical Exposure Electric Shock Ergonomics Fall From Heights Manual Handling Contact with Machinery Slip/Trip Striking Against Struck By Caught Between Transport/Vehicle Contact with hot surface Tools & Equipment Equipment Failure Other

  • Chemical Exposure
  • Electric Shock
  • Ergonomics
  • Fall From Heights
  • Manual Handling
  • Contact with Machinery
  • Slip/Trip
  • Striking Against
  • Struck By
  • Caught Between
  • Transport/Vehicle
  • Contact with hot surface
  • Tools & Equipment
  • Equipment Failure
  • Other

• Body Part Harmed

  Select Arm/Elbow/Wrist Left or Right Hand Finger Left or Right Back Eye Face Head Neck Nose Ear Toe/Knee/Ankle Left or Right Stomach/Chest Hearing Respiratory

  • Arm/Elbow/Wrist Left or Right
  • Hand Finger Left or Right
  • Back
  • Eye
  • Face
  • Head
  • Neck
  • Nose
  • Ear
  • Toe/Knee/Ankle Left or Right
  • Stomach/Chest
  • Hearing
  • Respiratory

• Left or Right

  Right

  Left

• Activity Being undertaken at the time of the event/hazard

• Name and contact of Witness

• Damage Details: Registration Number if applicable, Brief description of nature & extent of damage to plant, property or the environment

• Business Group

  Select Fleet Site (Shed) Site (Fabrication) Corporate Services Customer Care Finance Leadership Team

  • Fleet
  • Site (Shed)
  • Site (Fabrication)
  • Corporate Services
  • Customer Care
  • Finance
  • Leadership Team

• Contacted Manager

  Yes

  No

  N/A

• Who is your Manager

  Select Andrew Yeoland Clair Haines Dale Osborne David Thompson Eugenie Stragalinos Keiran Cross Paul Heggart Zane Foott

  • Andrew Yeoland
  • Clair Haines
  • Dale Osborne
  • David Thompson
  • Eugenie Stragalinos
  • Keiran Cross
  • Paul Heggart
  • Zane Foott

• Does this need to be followed by a Manager

  Yes

  No

  N/A

• By Which Manager

  Select Andrew Yeoland Clair Haines Dale Osborne David Thompson Eugenie Stragalinos Keiran Cross Paul Heggart Zane Foott

  • Andrew Yeoland
  • Clair Haines
  • Dale Osborne
  • David Thompson
  • Eugenie Stragalinos
  • Keiran Cross
  • Paul Heggart
  • Zane Foott

• Is this a Reportable Event

  Yes

  No

  N/A

• Date and Time

  Date

Event Preliminary Investigation

• Identify cause of Event/Root Cause

  Select Procedural Physical Behavioural

  • Procedural
  • Physical
  • Behavioural

• What is the Procedural Cause

  Select Inadequate SOP Inadequate Supervision Inadequate Hazard Identification Inadequate Risk Assessment Inadequate Provision of PPE Inadequate Operator Training Inadequate Work Instructions Inadequate Design or Construction Inadequate Task Unrealistic Scheduling Inadequate Equipment Provided/Used Other - write in Notes

  • Inadequate SOP
  • Inadequate Supervision
  • Inadequate Hazard Identification
  • Inadequate Risk Assessment
  • Inadequate Provision of PPE
  • Inadequate Operator Training
  • Inadequate Work Instructions
  • Inadequate Design or Construction
  • Inadequate Task
  • Unrealistic Scheduling
  • Inadequate Equipment Provided/Used
  • Other - write in Notes

• Please specify

  Select Inadequate or Absent Guarding Poor Work Station Design Poor Condition/Design of Equipment/Objects Incorrect Storage of Equipment/Objects Poor Lighting or Glare Inappropriate Clothing or Footwear Inappropriate Equipment Used Inadequate Fall Protection Inadequate Signage or Warning Signs Inadequate Controls or Chemicals/Substances Inadequate Noise Control Other - Please write in Notes

  • Inadequate or Absent Guarding
  • Poor Work Station Design
  • Poor Condition/Design of Equipment/Objects
  • Incorrect Storage of Equipment/Objects
  • Poor Lighting or Glare
  • Inappropriate Clothing or Footwear
  • Inappropriate Equipment Used
  • Inadequate Fall Protection
  • Inadequate Signage or Warning Signs
  • Inadequate Controls or Chemicals/Substances
  • Inadequate Noise Control
  • Other - Please write in Notes

• Please Specify

  Select Performing Task Without Authority Performing Task at Unsafe Speed Performing Task with Improper Technique Performing Task While Fatigued/Tired Performing Task Without Correct PPE Failure to Properly Secure Item/Load Making Safety Device Inoperable Using Incorrect or Tagged out Equipment Using Equipment in an Improper Manner Incorrect Manual Handling Technique Other - Please write in notes

  • Performing Task Without Authority
  • Performing Task at Unsafe Speed
  • Performing Task with Improper Technique
  • Performing Task While Fatigued/Tired
  • Performing Task Without Correct PPE
  • Failure to Properly Secure Item/Load
  • Making Safety Device Inoperable
  • Using Incorrect or Tagged out Equipment
  • Using Equipment in an Improper Manner
  • Incorrect Manual Handling Technique
  • Other - Please write in notes

• Comments on Root Cause Analysis

  Select Performing Task Without Authority Performing Task at Unsafe Speed Performing Task with Improper Technique Performing Task While Fatigued/Tired Performing Task Without Correct PPE Failure to Properly Secure Item/Load Making Safety Device Inoperable Using Incorrect or Tagged out Equipment Using Equipment in an Improper Manner Incorrect Manual Handling Technique Other - Please write in notes

  • Performing Task Without Authority
  • Performing Task at Unsafe Speed
  • Performing Task with Improper Technique
  • Performing Task While Fatigued/Tired
  • Performing Task Without Correct PPE
  • Failure to Properly Secure Item/Load
  • Making Safety Device Inoperable
  • Using Incorrect or Tagged out Equipment
  • Using Equipment in an Improper Manner
  • Incorrect Manual Handling Technique
  • Other - Please write in notes

Preventative Actions

• Due Date

  Date

• Reponsibility

  Select Andrew Yeoland Clair Haines Dale Osborne David Thompson Eugenie Stragalinos Keiran Cross Paul Heggart Zane Foott

  • Andrew Yeoland
  • Clair Haines
  • Dale Osborne
  • David Thompson
  • Eugenie Stragalinos
  • Keiran Cross
  • Paul Heggart
  • Zane Foott

• Interim Action

• Perminant Actions

• Completed By

  Select Andrew Yeoland Clair Haines Dale Osborne David Thompson Eugenie Stragalinos Keiran Cross Paul Heggart Zane Foott

  • Andrew Yeoland
  • Clair Haines
  • Dale Osborne
  • David Thompson
  • Eugenie Stragalinos
  • Keiran Cross
  • Paul Heggart
  • Zane Foott

• Is there Further investigation Required?

  Yes

  No

  N/A

• Comprehensive Investigation Details (Checklist) Event Investigation Checklist.docx

  Media

Sign Off

• Signed off by Manager when corrective actions have been adopted and monitored

  Sign