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

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