Incident Review - Full Investigation & Report

• Document No.

• Audit Title

• Site/Area

• Review conducted on

  Date

• Prepared by

• Location
  Address

Incident Details

• Date & Time of Incident

  Date
• Location of Incident
  Address

• Site Name

• Incident Severity?

  Urgent

  High

  Medium

  Low

  Trivial

• Incident Type (select all that apply)

  Select Hazard Near-Miss Slip & Fall Accident Injury Theft Fire Property Damage Fatality Illness Reportable / Notifiable Loss Time Other

  • Hazard
  • Near-Miss
  • Slip & Fall
  • Accident
  • Injury
  • Theft
  • Fire
  • Property Damage
  • Fatality
  • Illness
  • Reportable / Notifiable
  • Loss Time
  • Other

• Please describe type of incident

• Name of on-duty Duty Manager(s) or Team Leader(s), at time of incident?

• Was medical attention administered?

  Yes

  No

• What kind of medical attention was administered?

  Select First Aid Doctor Consulted Hospital Ambulance Medical Attention Declined

  • First Aid
  • Doctor Consulted
  • Hospital
  • Ambulance
  • Medical Attention Declined

• Please detail medical attention

Incident Summary

• Describe what happened. Please be detailed but state only facts.

• Do you wish to include a timeline of events for this incident?

  Yes

  No

Incident Timeline

• Build a timeline of key incident events below

Event

• Event Date / Time

  Date

• Event Description

• Did the incident take place inside or outside of the facility?

  Inside

  Outside

• Describe where the incident took place.

• What were the weather / environmental conditions at the time of the incident?

  Select Clear Cloudy Rain Snow Windy Heatwave Haze Other

  • Clear
  • Cloudy
  • Rain
  • Snow
  • Windy
  • Heatwave
  • Haze
  • Other

• Describe the weather / environmental conditions at the time of the incident

• Where in the facility did the incident take place?

Evidence & Attachments

• Which of the following do you need to attach to this report to accuractly document this incident?

  Select Evidence Equipment Details Vehicle Details Damages Other Items

  • Evidence
  • Equipment Details
  • Vehicle Details
  • Damages
  • Other Items

Evidence Log

• Please log all relevant evidence below

Evidence

• Evidence Description

• Evidence ID number (if applicable)

• Type of evidence

  Document

  Photos

  Other

• Photos of evidence (if applicable)

  Media

• Please detail any further information regarding this evidence (if applicable)

Vehicle Log

• Please log all relevant vehicle details below

Vehicle

• Vehicle Make

• Vehicle Model

• Vehicle Registration

• Driver (if applicable)

• Photos of equipment (if applicable)

  Media

• Please detail any further information regarding this vehicle (if applicable)

Damage Log

• Please log all relevant damage details below

Damage

• Damage description

• ID number (if applicable)

• Photos of damage (if applicable)

  Media

• Please detail any further information regarding this damage (if applicable)

Other Items Log

• Please log all relevant details of other items below

Item

• Item description

• ID number (if applicable)

• Photos of item (if applicable)

  Media

• Please detail any further information regarding this item (if applicable)

Equipment Log

• Please log all relevant equipment details below

Equipment

• Equipment Make

• Equipment Model

• Equipment ID number (if applicable)

• Photos of equipment (if applicable)

  Media

• Please detail any further information regarding this equipment (if applicable)

Persons Involved

• Please document all people involved in this incident

Person

Person

• Full Name

• Employee number (if applicable)

• Contact phone number

• What is this person's relation to the incident? (select all that apply)

  Select Reporter of incident Injured person/Casualty Witness Primary person involved Secondary Involvement On-duty Duty Manager On-duty Team Leader Lead Reviewer of Incident Other

  • Reporter of incident
  • Injured person/Casualty
  • Witness
  • Primary person involved
  • Secondary Involvement
  • On-duty Duty Manager
  • On-duty Team Leader
  • Lead Reviewer of Incident
  • Other

• Describe this person's relation to the incident

• Please describe this person's involvement with the incident, including all relevant information

• Attach any relevant photos regarding this person

  Media

• Do you want to log a statement for this person?

  Yes

  No

  N/A

Statement

• Statement regarding incident

• Person Signature

  Sign

• Date & Time of Statement

  Date

• Has this person sustained an injury?

  Yes

  No

Injury Details

• Type of injury or illness? (select all that apply)

  Select Superficial Open Wound Fatality Concussion Sprain Respiratory Eye Injury Burns Fracture Electrocution Fall Strain Dislocation Struck by object Entanglement Assault Muscle & Tendon Nerve & Spinal Cord Amputation Intracranial Other

  • Superficial
  • Open Wound
  • Fatality
  • Concussion
  • Sprain
  • Respiratory
  • Eye Injury
  • Burns
  • Fracture
  • Electrocution
  • Fall
  • Strain
  • Dislocation
  • Struck by object
  • Entanglement
  • Assault
  • Muscle & Tendon
  • Nerve & Spinal Cord
  • Amputation
  • Intracranial
  • Other

• Describe type of injury or illness

• Parts of body affected? (select all that apply)

  Select General Ailment Head Eye (Right) Eye (Left) Ear Nose Throat Neck Back (Upper) Back (Lower) Arm - Upper (Right) Arm - Upper (Left) Arm - Elbow (Right) Arm - Elbow (Left) Arm - Forearm (Right) Arm - Forearm (Right) Wrist (Right) Wrist (Left) Hand (Right) Hand (Left) Chest Abdominal / Stomach Groin / Anus Leg - Upper (Right) Leg - Upper (Left) Leg - Knee (Right) Leg - Knee (Left) Leg - Lower (Right) Leg - Lower (Left) Ankle (Right) Ankle (Left) Foot (Right) Foot (Left) Shoulder (Left) Shoulder (Right) Other

  • General Ailment
  • Head
  • Eye (Right)
  • Eye (Left)
  • Ear
  • Nose
  • Throat
  • Neck
  • Back (Upper)
  • Back (Lower)
  • Arm - Upper (Right)
  • Arm - Upper (Left)
  • Arm - Elbow (Right)
  • Arm - Elbow (Left)
  • Arm - Forearm (Right)
  • Arm - Forearm (Right)
  • Wrist (Right)
  • Wrist (Left)
  • Hand (Right)
  • Hand (Left)
  • Chest
  • Abdominal / Stomach
  • Groin / Anus
  • Leg - Upper (Right)
  • Leg - Upper (Left)
  • Leg - Knee (Right)
  • Leg - Knee (Left)
  • Leg - Lower (Right)
  • Leg - Lower (Left)
  • Ankle (Right)
  • Ankle (Left)
  • Foot (Right)
  • Foot (Left)
  • Shoulder (Left)
  • Shoulder (Right)
  • Other

• Please describe injury location

• Describe this injury or illness

• What was the cause of this injury or illness?

Review of Site Procedures

• Are there sections contained within the EAP that relate to the area of the premises in which the incident occurred?

Normal Operating Procedures (NOP)

• Does the facility operate by the use of an NOP and is this kept up to date and reviewed at regular intervals?

• Are there sections contained within the NOP that relate to the area of the premises in which the incident occurred?

• Does the NOP properly reflect normal working practise at the time of incident?

• Have employees on site concerned with the area of the premises in which the incident occurred, and other employees involved directly with the incident, received appropriate familiarisation in the contents of the NOP and are there sufficient records to demonstrate this?

• Review of Information contained within NOP

Emergency Action Plan (EAP)

• Does the facility prepare for emergencies by the use of an EAP and is this kept up to date and reviewed at regular intervals?

• Are there sections contained within the EAP that relate specifically to how staff on site should respond to this type of incident?

• Does the EAP properly reflect the response to this incident?

• Have employees on site concerned with the area of the premises in which the incident occurred, and other employees involved directly with the incident, received appropriate familiarisation in the contents of the EAP and are there sufficient records to demonstrate this?

• Review of Information contained within EAP

Review of Site Risk Assessments

Area Specific Risk Assessments

• Has a risk assessment been conducted by a competent person for the area of the facility in which the incident occurred?

• Is the assessment reviewed at regular intervals by a competent person?

• Has the risk assessment taken into consideration all foreseeable risk and does it contain all relevant information relating to this area of the facility?

• Have employees on site concerned with the area of the premises in which the incident occurred, and other employees involved directly with the incident, received appropriate familiarisation in the contents of the risk assessment and are there sufficient records to demonstrate this?

• Review of Information contained within the Risk Assessment

First Aid & Emergency Needs Assessments

• Has a first aid needs analysis assessment been conducted for this facility?

• Can aid and/or assistance be summoned to the area of the facility in which this incident occurred without unnecessary delay and was this the case at the time when the incident occurred?

• At the time of incident, was there adequate provision of first aid and emergency equipment for the facility and if used, was this as per first aid and emergency procedures for the facility?

• Does the site possess any specialist emergency equipment (e.g. defibrillator, spinal board), and if so, was any such equipment used when administering any treatment? If used, was this as per standard first aid and emergency procedures for the facility?

• Were suitably qualified staff available to respond to this incident? Was the response reflective of site procedures?

Root Cause Analysis & Contributing Factors

• Were there any identifiable contributory factors to this incident occurring?

  Select Yes No

  • Yes
  • No

• Summary of Contributory Factors

• A Root Cause Analysis (RCA) is the process of determining the cause of an incident. It requires consideration of all the factors that may have contributed to this incident occurring and an in depth understanding of the underlying cause.

• Has the root cause of this issue been able to be identified?

  Yes

  No

  N/A

• Why is the root cause for this issue unable to be identified at this time?

• How likely is this incident to reoccur in future?

  Select Certain Very Likely Likely Unlikely Very Unlikely Never Unclear / Not Determinable

  • Certain
  • Very Likely
  • Likely
  • Unlikely
  • Very Unlikely
  • Never
  • Unclear / Not Determinable

• What is the root cause of this incident? Please consider and include all contributing factors

• Has the root cause of this issue been rectified or eliminated?

  Yes

  No

• How was the root cause rectified or eliminated?

• Please attach any relevant photos or media

  Media

• Please provide any relevant further details

• How likely is this incident to reoccur in future?

  Select Certain Very Likely Likely Unlikely Very Unlikely Never Unclear / Not Determinable

  • Certain
  • Very Likely
  • Likely
  • Unlikely
  • Very Unlikely
  • Never
  • Unclear / Not Determinable

Corrective Actions

• Are corrective actions required with regard to this incident?

  Yes

  No

• Please add any corrective actions to this section before completing this incident review.

Recommendations

• Are there any recommendations with regard to this incident?

  Yes

  No

  N/A

• Please list all recommendations in this section before completing this incident review.

Additional Provisions

• Are there any additional provisions with regard to this incident?

  Yes

  No

  N/A

• Please list all additional provisions in this section before completing this incident review.

Report Summary

• Report Summary

• Further action/follow-up/investigation/review required?

  Yes

  No

• Name of person/people to follow up

• Name & Signature of the Lead Reviewer of the Incident

  Sign