Incident Report

• Site
  Address

• Reported to:

• Date Reported

  Date

• Document No.

• Person who reported the incident to (company name):

• Date & time incident occurred:

  Date

• Brief description of the incident:

• Type of incident

  Injury

  Near Miss

  Damage or Theft

Incident Details

• Full details of the incident:

• Immediate actions taken:

• Witnesses

Witness

• Name:

• Contact Number:

• Statement

• Attach Photos

Photo

• Attach photos

  Media

• Deaths and life-threatening injuries, like amputations, must be reported to Worksafe immediately.
  Other serious incidents, such as those listed below, should be reported as soon as the employer is aware of the incident:
  • a person requires medical treatment:
  • after exposure to a substance,
  • as an inpatient in hospital, or
  • for a serious injury such as a head or eye injury, electric shock, spinal injuries or serious laceration (stitches
  required).
  Once aware of an incident that falls under any of the above categories you must call the Construction Manager or other OHS resource nominated by (Company Name) and ensure works at the site cease immediately. The site must also be preserved if safe to do so until directed otherwise by Worksafe.

• Details of the injured person(s)

Injured Person

• Person Type

  Select Contractor Employee Public

  • Contractor
  • Employee
  • Public

• Name:

• Date of Birth:

  Date

• Contact number

• Occupation

• Employer:

Details of the Injury

• Primary Injury

  Select Laceration Sprains and strains Superficial injury Concussion Electrocution Bruising or crushing injury, excluding those with fracture Penetration of foreign object Fractures (excluding of vertebral column) Fracture of vertebral column Dislocations Internal injury of chest, abdomen and pelvis Traumatic amputation, including loss of eyeball Foreign body on external eye, in ear or nose or in respiratory system (incl choking) Effects of weather or exposure Multiple injuries (only to be used where no principal injury can be identified) Other not listed

  • Laceration
  • Sprains and strains
  • Superficial injury
  • Concussion
  • Electrocution
  • Bruising or crushing injury, excluding those with fracture
  • Penetration of foreign object
  • Fractures (excluding of vertebral column)
  • Fracture of vertebral column
  • Dislocations
  • Internal injury of chest, abdomen and pelvis
  • Traumatic amputation, including loss of eyeball
  • Foreign body on external eye, in ear or nose or in respiratory system (incl choking)
  • Effects of weather or exposure
  • Multiple injuries (only to be used where no principal injury can be identified)
  • Other not listed

• Bodily Location

  Select Face Head (other than eye, ear and face) Neck Spine Trunk (excluding internal organs) Shoulders and arms Hands and fingers Hips and legs Feet and toes Internal organs Multiple locations General and unspecified locations

  • Face
  • Head (other than eye, ear and face)
  • Neck
  • Spine
  • Trunk (excluding internal organs)
  • Shoulders and arms
  • Hands and fingers
  • Hips and legs
  • Feet and toes
  • Internal organs
  • Multiple locations
  • General and unspecified locations

Description of Occurrence of Injury

• In which part of the workplace did the injury occur?

• What was Person Involved doing at the time?

• What happened unexpectedly?

• How exactly was the injury or disease sustained?

• Incidents where employees or other persons are in the immediate vicinity of a risk such as:
  • registered or licensed plant that has collapsed, overturned, failed or malfunctioned
  • collapse of an excavation supporting an excavation
  • collapse of a building or structure
  • implosion, explosion or fire
  • incidents involving Dangerous Goods
  • plant or objects falling from high places
  Once aware of an incident that falls under any of the above categories you must call the Construction Manager or other OHS resource nominated by (Company Name) and ensure works at the site cease immediately. The site must also be preserved if safe to do so until directed otherwise by Worksafe.

• Details of the person(s) involved

Person Involved

• Person Type

  Select Contractor Employee Public

  • Contractor
  • Employee
  • Public

• Name:

• Contact number

• Employer:

• In which part of the workplace did the incident occur?

• What was worker doing at the time?

• What happened unexpectedly?

• Property or equipment that was damaged/stolen

• Task that was being performed at the time:

• Was the activity part of normal duties?

  Yes

  No

Incident Classification

• Likelihood Descriptors

  

• Likelihood

  Almost Certain

  Likely

  Occasional

  Unlikely

  Rare

• Consequence Descriptors

  

• Consequence

  Negligible

  Minor

  Moderate

  Major

  Catastrophic

• Risk Matrix

  

• Incident Category

  Very Low

  Low

  Medium

  High

• Add signature

  Sign

• Injury Classification

  Lost Time Injury

  Medical Treatment

  First Aid Treatment

  Permanent Disability

  Fatality

• Externally Reportable?

  Yes

  No

• Reported to Worksafe?

  Yes

  No

• Worksafe Reference Number

Incident Analysis

• Breakdown Agency:

  Select Machinery and fixed plant Mobile plant Road transport Powered equipment, tools and appliances Non-powered hand tools Non-powered equipment Chemicals Other materials, substances or objects Outdoor environment Indoor environment Animals Human agencies Unspecified agencies

  • Machinery and fixed plant
  • Mobile plant
  • Road transport
  • Powered equipment, tools and appliances
  • Non-powered hand tools
  • Non-powered equipment
  • Chemicals
  • Other materials, substances or objects
  • Outdoor environment
  • Indoor environment
  • Animals
  • Human agencies
  • Unspecified agencies

• Mechanism of Injury:

  Select Falls from a height Falls on the same level (including trips and slips) Hitting objects with a part of the body Being hit by moving objects Repetitive movement with low muscle loading Other muscular stress Contact with electricity Contact or exposure to heat and cold Insect and spider bites and stings Slide or cave-in Vehicle Incident Other and multiple mechanisms of injury Unspecified mechanisms of injury

  • Falls from a height
  • Falls on the same level (including trips and slips)
  • Hitting objects with a part of the body
  • Being hit by moving objects
  • Repetitive movement with low muscle loading
  • Other muscular stress
  • Contact with electricity
  • Contact or exposure to heat and cold
  • Insect and spider bites and stings
  • Slide or cave-in
  • Vehicle Incident
  • Other and multiple mechanisms of injury
  • Unspecified mechanisms of injury

• Agency of Injury:

  Select Machinery and fixed plant Mobile plant Road transport Powered equipment, tools and appliances Non-powered hand tools Non-powered equipment Chemicals Other materials, substances or objects Outdoor environment Indoor environment Animals Human agencies Unspecified agencies

  • Machinery and fixed plant
  • Mobile plant
  • Road transport
  • Powered equipment, tools and appliances
  • Non-powered hand tools
  • Non-powered equipment
  • Chemicals
  • Other materials, substances or objects
  • Outdoor environment
  • Indoor environment
  • Animals
  • Human agencies
  • Unspecified agencies

Outcome of Injury or disease (complete when information becomes available)

• Serious Bodily Injury?

  Yes

  No

• Rehabilitation Required?

  Yes

  No

• Rehabilitation Commencement Date:

  Date

• Resumption of work:

  Short term alternative duties

  Permanent alternative duties

  Normal duties

• Date:

  Date

• Date:

  Date

• Date:

  Date

Immediate Contributing Factors

• Substandard Conditions

  Select Inadequate guards or barriers Inadequate or improper protective equipment Defective tools, equipment or materials Congested or restricted action Inadequate warning system Fire and explosion hazards Poor housekeeping Hazardous environmental conditions (Gasses, dust, smoke, fumes etc) Noise exposures High or low temperature exposures Inadequate ventilation

  • Inadequate guards or barriers
  • Inadequate or improper protective equipment
  • Defective tools, equipment or materials
  • Congested or restricted action
  • Inadequate warning system
  • Fire and explosion hazards
  • Poor housekeeping
  • Hazardous environmental conditions (Gasses, dust, smoke, fumes etc)
  • Noise exposures
  • High or low temperature exposures
  • Inadequate ventilation

• Substandard Acts/Practices

  Select Operating without authority Failure to warn Failure to secure Operating at improper speed Failure to follow procedures Removing or making safety devices inoperable Using defective equipment Using equipment improperly Failure to use PPE equipment properly Improper loading Improper placement Improper lifting Improper position for task Servicing equipment while in operation Horseplay Under influence of alcohol or drugs

  • Operating without authority
  • Failure to warn
  • Failure to secure
  • Operating at improper speed
  • Failure to follow procedures
  • Removing or making safety devices inoperable
  • Using defective equipment
  • Using equipment improperly
  • Failure to use PPE equipment properly
  • Improper loading
  • Improper placement
  • Improper lifting
  • Improper position for task
  • Servicing equipment while in operation
  • Horseplay
  • Under influence of alcohol or drugs

• Details

Root Causes

• Job/System Factors

  Select Inadequate leadership/supervision Inadequate instruction Inadequate training Inadequate engineering/design Inadequate purchasing Inadequate work procedures Inadequate tools/equipment Inadequate maintenance Wear and tear Abuse or misuse

  • Inadequate leadership/supervision
  • Inadequate instruction
  • Inadequate training
  • Inadequate engineering/design
  • Inadequate purchasing
  • Inadequate work procedures
  • Inadequate tools/equipment
  • Inadequate maintenance
  • Wear and tear
  • Abuse or misuse

• Personal Factors

  Inadequate capability

  Lack of knowledge

  Lack of skill

  Stress

  Improper motivation

• Details

Investigation Report

• Control Strategy:

  Select Elimination Substitution Engineering Administration Personal Protective Equipment

  • Elimination
  • Substitution
  • Engineering
  • Administration
  • Personal Protective Equipment

• Recommendations