INCIDENT REPORT

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

DESCRIPTION OF EVENTS

• Cooper & Oxley Site:

• Name of injured party:

• Employer:

• Description of Incident: (who,what,where,when,why)....

• Type of injury sustained:

  Near Miss

  Injury sustained

• Go on to part 2

• Persons Injured

• Structural Damage

• Environmental Damage

• Other

• Please specify:

OCCURRENCE DETAILS (Part 2)

• Specify:

  Date

• Approximately:

  Date

• Weather Condition:

• Fine

• Warm

• Hot

• Cool

• Cold

• Cloudy

• Wet

• Windy

• Type of Injury sustained:

• Type of injury:

  Select FIRST AID CLINIC HOSPITAL AGGRAVATED RECURRENCE MAJOR MEDICAL TREATMENT LOST TIME INJURIE FATALITY

  • FIRST AID
  • CLINIC
  • HOSPITAL
  • AGGRAVATED RECURRENCE
  • MAJOR MEDICAL TREATMENT
  • LOST TIME INJURIE
  • FATALITY

• Clinic

• Hospital

• Aggravated Recurrence

• (Major) Medical treatment of Loss Time Injurie

• Fatality

• First Aid

• Protective Equipment Worn

• Helmet

• High Visible Vest/Top

• Boots

• Gloves

• Ear protection

• Eye protection

• Face shield

• Mask (respiratory protection)

INCIDENT DETAILS (part 3)

• Select date

  Date

• Place: (Describe)

• Working at Heights

• Working at ground level

• Authority Notified:

• Work Team Leader

• Site Managment

• OHSE

• Location (where)

• Head/Face

• Eye

• Ear

• Neck

• Shoulder

• Body/Skin

• Back/Spine

• Arm/Elbow

• Hand/Wrist

• Leg/Knee

• Foot/Ankle

• Multiple

• Other

• Specify:

• Nature of injury (What)

• Fracture

• Sprain/strain

• Dislocation

• Internal

• Laceration (wound)

• Bruise/crushing

• Foreign body

• Hearing impairment

• Burn

• Superficial (scratch)

• Asphyxia

• Heart attack

• Illness

• Multiple

• Other

• Specify:

• Agency (How)

• Machinery/Fixed Plant

• Mobile plant

• Road transport

• Other transport

• Powered equipment tools

• Non powered hand tools

• Chemicals

• Other materials / substances

• Specify:

• Outdoor environment

• Indoor environment

• Underground environment

• Unspecified agencies

• Other

• Specify:

• Mechanism (How)

• Fall from heights

• Fall from same level

• Strike against

• Struck by

• Repetitive movement

• Other muscular stress

• Specify:

• Contact with electricity

• Exposure to:

• Select Heat Cold Substance Pressure Noise Vibration

  • Heat
  • Cold
  • Substance
  • Pressure
  • Noise
  • Vibration

• Specify:

• Excavation cave in

• Caught between

• Other

• Specify:

DECLARATION

• Site manager:

  Sign

• Injured person/ Witness:

  Sign

• OHSE:

  Sign