Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

DESCRIPTION OF EVENTS

  • Cooper & Oxley Site:

  • Name of injured party:

  • Employer:

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

  • Type of injury sustained:

  • Go on to part 2

  • Persons Injured

  • Structural Damage

  • Environmental Damage

  • Other

  • Please specify:

OCCURRENCE DETAILS (Part 2)

  • Specify:

  • Approximately:

  • Weather Condition:

  • Fine

  • Warm

  • Hot

  • Cool

  • Cold

  • Cloudy

  • Wet

  • Windy

  • Type of Injury sustained:

  • Type of injury:

  • 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

  • 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:

  • Specify:

  • Excavation cave in

  • Caught between

  • Other

  • Specify:

DECLARATION

  • Site manager:

  • Injured person/ Witness:

  • OHSE:

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