Incident/Injury Report Form
Type of injury or disease (e.g burn)
Part/s of the body affected
Was medical treatment given?
- First Aid
Time lost due to injury?
How many hours/days?
How did the injury happen?
How long had you been working prior to the incident?
How long had you been working on this task?
Is this task part of your normal duties?
Have you been trained for this task?
What were you doing in the time prior to the incident?
Are there any other factors involved (e.g management, work environment, equipment) involved?
What do you think could have been done to prevent this from occuring?
Other comments or observations
- Manual Handling
- Occupational Overuse Syndrom
- Hazardous Substances
- Foreign body
- Hazardous substance
Safe Work Method Statements followed?
Equipment in good condition?
Appropriate safety equipment used?
Housekeeping issues contributed?
- High Heels
Workload boring and repetitive?
Is it a slip or trip?
Height of fall
- Turning a corner
- Going up
- Going down
What were you carrying (if anything) at that time?
Does it involve manual handling?
Were your items within easy reach?
Ergonomic equipment available?
Was the equipment being used correctly?
Repititive and forceful movements used?
Weight of object
Distance carried/position of object moved from/to
Height of load
Comments and Observation
- Elimination of the task
- Substition or another way of doing the task
- Engineer a way to make the job safer
- Administration or improve work practices
- Personal Protective Equipment