Title Page
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
PERSONAL DETAILS
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PLEASE PROVIDE ALL RELEVANT INFORMATION REGARDING THE PERSON INJURED
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FULL NAME
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DATE OF BIRTH
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SEX
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CONTACT NUMBER (PHONE/MOBILE)
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EMAIL ADDRESS
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ADDRESS
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OCCUPATION
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ARE YOU?
INJURY/INCIDENT DETAILS
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DATE AND TIME OF INCIDENT
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LOCATION
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HOW DID THE INCIDENT HAPPEN?
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NAME OF WITNESS/ES:
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TYPE OF INJURY OR DISEASE (E.G BURN)
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PART/S OF THE BODY AFFECTED. (DRAW AND ENCIRCLE THE PART/S AFFECTED)
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WAS MEDICAL TREATMENT GIVEN?
IF RESPONSE IS OTHER, PLEASE SPECIFY.
INVESTIGATION CHECKLIST AND ACTION REPORT FORM
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HOW DID YOU THINK THE INJURY HAPPENED?
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WHAT WERE YOU DOING THAT TIME?
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INVESTIGATION CHECKLIST
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HOW LONG HAD YOU BEEN WORKING PRIOR TO THE INJURY?
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HOW LONG HAD YOU BEEN WORKING ON THIS TASK?
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IS THIS TASK PART OF YOUR NORMAL DUTY?
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HAVE YOU BEEN TRAINED IN THIS TASK?
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ARE THERE ANY OTHER FACTORS INVOLVED? (E.G MANAGEMENT, EQUIPMENT, MAINTENANCE, INDIVIDUAL)
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WHAT DO YOU THINK YOU COULD HAVE DONE TO PREVENT THIS INJURY FROM OCCURRING?
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PLEASE ENCIRCLE THE MOST APPROPRIATE RESPONSE/S
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WHAT SORT OF INJURY OCCURRED?
- MANUAL HANDLING
- BRUISES/CUTS/BURNS
- FALLS/SLIPS/TRIPS
- HAZARDOUS SUBSTANCES
- OTHER
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SAFE WORK METHOD STATEMENTS FOLLOWED?
TO BE COMPLETED BY WHS MANAGER
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NAME OF WHS MANAGER:
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SIGNED:
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NAME OF SUPERVISOR:
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SIGNED:
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INVESTIGATOR'S COMMENTS AND OBSERVATIONS:
