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

• Employee / Contractor / Visotor

• Occupation

• Contact number

• Home address

• Email address

Injury Details

• Type of injury or incident

• Part/s of the body affected or equipment affected

• Date and Time of injury or incident

  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 or incident?

  Yes

  No

  N/A

• How many hours/days?

• How did the injury or incident 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 or damage occurred?

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

  • Manual Handling
  • Occupational Overuse Syndrom
  • Cuts
  • Bruises
  • Burns
  • Falls
  • Slips
  • Trips
  • Vehicles
  • Equipment
  • 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 Grass Dirt Sand Gravel Rocks Road Dry Wet Footpath Torn Damaged Other

  • Cement
  • Grass
  • Dirt
  • Sand
  • Gravel
  • Rocks
  • Road
  • Dry
  • Wet
  • Footpath
  • 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