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
Section A: PERSONAL and INCIDENT DETAILS
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Title
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Last Name:
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First Name:
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Date of Birth:
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Are you relevant worker / contractor / visitor?
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Sex:
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Occupation:
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Email address:
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Phone (W):
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Phone (H):
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Home address:
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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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Signed:
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Select date
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Name/s of Witness/es
Person
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Name of Witness:
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Phone:
Section B: SUPERVISOR or WORKSHOP MANAGER NOTIFICATION
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MANAGER or SUPERVISOR NOTIFICATION?
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Name of WHS Manager:
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Date and time of incident:
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Signed:
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Date:
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Phone:
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Name of Supervisor:
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Date and time of incident:
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Signed:
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Date:
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Phone:
Section C: INJURY DETAILS (if applicable) Use this section to also report workplace disease.
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Details of injury or disease are applicable?
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Type of injury or disease (e.g burn)
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Parts of the body affected:
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Date and time when symptoms noticed:
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Was medical treatment given? (CAN BE MULTIPLE SELECTION)
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Name of person giving initial treatment:
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Date and time initial treatment given:
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There's a time lost due to injury?
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How many hours?
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How many days?
PART 2: INVESTIGATION CHECKLIST AND ACTION REPORT FORM
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Incident / Injury: How do you think the incident / injury happened and what were you doing at the time?
Investigation Checklist:
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How long had you been working prior to the incident / 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 duties?
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Have you been instructed / trained in this task?
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What were you doing in the time prior to the incident / injury?
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Are there any other factors involved (e.g. management, the work environment, equipment, maintenance, individual)?
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Give factors:
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What do you think could have been done to prevent this incident from occurring?
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Any other comments or observations?
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Comment / Observation:
Please answer / tick the most appropriate response/s:
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What sort of incident / injury occurred? (CAN BE MULTIPLE SELECTIONS)
- Manual handling
- Occupational Overuse Syndrome (OOS)
- cuts
- bruises
- burns
- falls
- slips
- trips
- vehicles
- bicycles
- hazardous substances
- insects
- animals
- foreign body
- plant
- stress
- other
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Please specify:
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Type of injury: (CAN BE MULTIPLE SELECTION)
- Sting
- bite
- kick
- puncture
- strain
- sprain
- hazardous substances
- slip
- strip
- fall
- other
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Please specify:
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Safe Work Method Statements followed?
Identification of equipment/object/insect involved:
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If there's equipment/object/insect involved?
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Equipment in good condition?
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Date of last service of equipment
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Appropriate safety equipment (PPE) used?
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Lighting adequate?
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Housekeeping issues contributed?
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Surface type? (Multiple Selection)
- Cement
- Tile
- Grass
- Dry
- Wet
- Damaged
- Torn
- Sand
- Footpath
- Carpet
- Gravel
- Rocks
- Road
- Other
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Please specify:
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Type of shoes worn:
- Open
- Closed
- Boots
- High heels
- Sandals
- none
- other
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Please specify:
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Workload excessive?
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Workload boring and repetitive?
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If it was a slip or trip?
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Height of fall / slip / trip?
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Were you running / walking / turning a corner / jumping / other?
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Please specify:
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If stairs - going up / going down?
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Did you fall on your front / back / side?
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What were you carrying (if anything) at the time?
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Please specify:
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If the incident involves manual handling?
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Were work items within easy reach?
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Ergonomic equipment available?
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Was the equipment being used correctly?
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Repetitive and/or forceful movements used?
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Action involved: (CAN BE MULTIPLE SELECTION)
- reaching
- bending
- stooping
- sitting
- kneeling
- twisting
- pushing
- pulling
- lifting
- catching
- lowering
- carrying
- other
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Please specify:
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Weight of object?
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Distance carried / position of object moved from / to?
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Height of load?
PART 3: TO BE COMPLETED BY WHS MANAGER
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investigator's comments and observations from part 2:
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RISK CONTROL OPTIONS:
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Personal Protective Equipment / PPE (ACTION REQUIRED)
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By Whom:
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By When:
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Can you improve work practices? e.g. limit time of exposure. (ACTION REQUIRED)
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By Whom:
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By When:
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Can you engineer a way to make the job safer? (ACTION REQUIRED)
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By Whom:
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By When:
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Is there another way you can do the task? (ACTION REQUIRED)
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By Whom:
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By When:
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Do you have to do the task? (ACTION REQUIRED)
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By Whom:
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By When:
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Date feedback provided to person reporting the injury/incident:
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Signed:
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Print Name:
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Phone no.
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Position:
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Date:
Office Use Only (Health and Safety Recommendations)
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OT:
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Date PART 2 received:
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Date Completed:
