Incident Report

• Site conducted

  Select

• 

• Report Date

  Date

• Prepared by

• Location
  Address

Employee/Worker Details

• Name

• Address
  Address

• Date of Birth

  Date

• Gender

  Male

  Female

• Phone Number

Employment Details

• Job Title

• Was this a Sub Contractor or RJA Employee ?

  RJA Employee

  Contractor

• Notify Lyndon Hawkins and Stephen Pauley - 0418 171 270

• Name of the Contracting Company

• Notify the Contracting Company of the incident

• Request the Contracting Company provide you an Incident form

Accident/Near Miss Details

• Date & Time of Incident

  Date

• How long was the person working prior to the incident ?

• Accident Type

  Select Near Miss - Minor (First Aid Treatment) Near Miss - Major (Hospitalisation or Death) Incident - No Lost Time Incident - Lost Time Injury

  • Near Miss - Minor (First Aid Treatment)
  • Near Miss - Major (Hospitalisation or Death)
  • Incident - No Lost Time
  • Incident - Lost Time Injury

• Treatment Given

  No Treatment

  First Aid

  Doctor

  Hospital

  Serious Harm

Injury Details

• Nature of Injury

  Select No Injury Sprain/Strain Bruising Cut Burns Head Injury Poison/Chemical Fracture/Break Multiple Injuries Gradual Process

  • No Injury
  • Sprain/Strain
  • Bruising
  • Cut
  • Burns
  • Head Injury
  • Poison/Chemical
  • Fracture/Break
  • Multiple Injuries
  • Gradual Process

• WHERE did the Accident/Near Miss Happen?

• HOW did the Accident/Near Miss Happen?

• Was the person competent for the task ?

  Yes

  No

• How serious could the injuries have been?

• Did the person get ADMITTED to hospital ?

  No

  Yes

Details

• What happened?

• Take at least 5 Photos of the incident area and injury (if possible)

  Media

• What was the ROOT CAUSE of this issue (Why did it occur)?

Completion

• Has the Safety Officer and/or Lyndon Hawkins been notified ?

  Yes

  No

• Worker

  Sign

• Site Foreman/Witness/Supervisor

  Sign