Title Page

Personal and Incident Details Part I

  • Title:

  • Last Name:

  • First Name:

  • Other Name/s:

  • Home Address:

  • Date of Birth

  • Sex:

  • Date and time of incident:

  • How did the incident happen?

  • Location

  • Insert location photo:

  • Signature:

  • Date:

Supervisor or Workshop Manager Notification

  • Name of WHS Manager:

  • Date and time of incident:

  • Signature:

  • Date:

  • Phone:

  • Name of Supervisor:

  • Date and time of incident:

  • Signature:

  • Date:

  • Phone:

Investigation Checklist and Action Report Form Part II

  • Incident/Injury: State how incident/injury happened

  • Injury Details (If Applicable) Use this section to also report workplace disease.

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

  • Part/s of body affected:

  • Date and time when symptoms noticed:

  • Was medical treatment given?

  • Name of person giving initial treatment:

  • Date and time initial treatment given:

  • Time lost due to injury?

  • How many hours/days?

Investigation Checklist:

  • How long had you been working prior to the incident/injury?

  • How long had you been working on this task?

  • Is this task part of your normal duties?

  • Have you been instructed/trained in this task?

  • What were you doing in the time prior to the incident/injury?

  • Are there any factors involved (e.g. management, the work environment, equipment, maintenance, individual)?

  • If your answer is yes, discuss:

  • What do you think could have been done to prevent this incident from occuring?

  • Any other comment or observations?

  • Please answer/select the most appropriate response/s:

  • What sort of incident/injury occurred?

  • If others (state answer)

  • Type of injury:

  • If others (state answer)

  • Safe Work Method Statements followed?

  • Identification of equipment/object/insect involved:

  • Equipment in good condition?

  • Date of last service equipment:

  • Appropriate safety equipment (PPE) used?

  • Lighting adequate?

  • Housekeeping issues contributed?

  • Type of shoes worn:

  • If others (specify)

  • Surface type:

  • If others (specify)

  • Workload excessive?

  • Workload boring and repetitive?

  • If it was a slip or trip:

  • Height of fall/slip/trip?

  • Were you running, walking, turning a corner, jumping, other?

  • If stairs? going up or going down?

  • Did you fall on your front, back or side?

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

  • If the incident involves manual handling:

  • Were work items within easy reach?

  • Ergonomic equipment available?

  • Was the equipment being used correctly?

  • Repititive and forceful movement used?

  • Action involved:

  • Weight of object?

  • Distance carried/position of object moved from/to?

  • Height of load?

Completed by the person or persons involved

  • Full name

  • Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.