Incident/Injury Report Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Personal and Incident Details

• Full Name

• Date of Birth

  Date

• Sex

  Select Male Female

  • Male
  • Female

• Occupation

• Contact number

• Home address

• Email address

Injury Details

• Type of injury or disease (e.g burn)

• Part/s of the body affected

• Date and Time of symptoms

  Date

• Was medical treatment given?

  Yes

  No

  N/A

• Treatment provided

  Select First Aid Doctor Nurse Hospital Other

  • First Aid
  • Doctor
  • Nurse
  • Hospital
  • Other

• Provider

• Date and Time of treatment

  Date

• Time lost due to injury?

  Yes

  No

  N/A

• How many hours/days?

• How did the injury happen?

Investigation

• 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?

  Yes

  No

  N/A

• Have you been trained for this task?

  Yes

  No

  N/A

• 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

• What sort of injury occurred?

  Select Manual Handling Occupational Overuse Syndrom Cuts Bruises Burns Falls Slips Trips Vehicles Bicycles Hazardous Substances Insects Animals Foreign body Plant Stress Other

  • Manual Handling
  • Occupational Overuse Syndrom
  • Cuts
  • Bruises
  • Burns
  • Falls
  • Slips
  • Trips
  • Vehicles
  • Bicycles
  • Hazardous Substances
  • Insects
  • Animals
  • Foreign body
  • Plant
  • Stress
  • Other

• Type of injury?

  Select Sting Bite Kick Puncture Strain Sprain Hazardous substance Slip Trip Fall Other

  • Sting
  • Bite
  • Kick
  • Puncture
  • Strain
  • Sprain
  • Hazardous substance
  • Slip
  • Trip
  • Fall
  • Other

• Safe Work Method Statements followed?

  Yes

  No

  N/A

• Equipments/objects/insects involved?

  Yes

  No

  N/A

• Equipment in good condition?

  Yes

  No

  N/A

• Date of last service of equipment

  Date

• Appropriate safety equipment used?

  Yes

  No

  N/A

• Lighting adequate?

  Yes

  No

  N/A

• Housekeeping issues contributed?

  Yes

  No

  N/A

• Surface type

  Select Cement Tile Grass Sand Footpath Carpet Gravel Rocks Road Dry Wet Torn Damaged Other

  • Cement
  • Tile
  • Grass
  • Sand
  • Footpath
  • Carpet
  • Gravel
  • Rocks
  • Road
  • Dry
  • Wet
  • Torn
  • Damaged
  • Other

• Type of shoes worn

  Select Open Close Boots High Heels Sandals None Other

  • Open
  • Close
  • Boots
  • High Heels
  • Sandals
  • None
  • Other

• Workload excessive?

  Yes

  No

  N/A

• Workload boring and repetitive?

  Yes

  No

  N/A

• Is it a slip or trip?

  Yes

  No

  N/A

• Height of fall

• Were you -

  Select Running Walking Turning a corner Jumping

  • Running
  • Walking
  • Turning a corner
  • Jumping

• If stairs -

  Going up

  Going down

  N/A

• Did you fall on your -

  Back

  Front

  Side

• What were you carrying (if anything) at that time?

• Does it involve manual handling?

  Yes

  No

  N/A

• Were your items within easy reach?

  Yes

  No

  N/A

• Ergonomic equipment available?

  Yes

  No

  N/A

• Was the equipment being used correctly?

  Yes

  No

  N/A

• Repititive and forceful movements used?

  Yes

  No

  N/A

• Action involved

  Select Reaching Bending Stooping Sitting Kneeling Twisting Pulling Pushing Lifting Catching Lowering Carrying

  • Reaching
  • Bending
  • Stooping
  • Sitting
  • Kneeling
  • Twisting
  • Pulling
  • Pushing
  • Lifting
  • Catching
  • Lowering
  • Carrying

• Weight of object

• Distance carried/position of object moved from/to

• Height of load

For the WHS Manager

• Comments and Observation

• Recommendation

  Select 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

  • 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

• Person assigned

• Target Date

  Date

Supervisor or WHS Manager Notification

• Supervisor

  Sign

• WHS Manager

  Sign