Incident/Injury Report Form

Personal and Incident Details Part I

• Title:

• Last Name:

• First Name:

• Other Name/s:

• Home Address:

• Yes

  No

  N/A

• Date of Birth

  Date

• Sex:

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Date and time of incident:

  Date

• How did the incident happen?

• Location

• Insert location photo:

• Signature:

  Sign

• Date:

  Date

Supervisor or Workshop Manager Notification

• Name of WHS Manager:

• Date and time of incident:

  Date

• Signature:

  Sign

• Date:

  Date

• Phone:

• Name of Supervisor:

• Date and time of incident:

  Date

• Signature:

  Sign

• Date:

  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:

  Date

• Was medical treatment given?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Name of person giving initial treatment:

• Date and time initial treatment given:

  Date

• Time lost due to injury?

  Yes

  No

  N/A

• How many hours/days?

  Yes

  No

  N/A

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)?

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• If others (state answer)

• Type of injury:

  Yes

  No

  N/A

• If others (state answer)

• Safe Work Method Statements followed?

  Yes

  No

  N/A

• Identification of equipment/object/insect involved:

• Equipment in good condition?

  Yes

  No

  N/A

• Date of last service equipment:

  Date

• Appropriate safety equipment (PPE) used?

  Yes

  No

  N/A

• Lighting adequate?

  Yes

  No

  N/A

• Housekeeping issues contributed?

  Yes

  No

  N/A

• Type of shoes worn:

  Select Open closed boots high heels sandals none others

  • Open
  • closed
  • boots
  • high heels
  • sandals
  • none
  • others

• If others (specify)

• Surface type:

  Select Cement tile grass dry wet damaged torn sand footpath carpet gravel rocks road other

  • Cement
  • tile
  • grass
  • dry
  • wet
  • damaged
  • torn
  • sand
  • footpath
  • carpet
  • gravel
  • rocks
  • road
  • other

• If others (specify)

• Workload excessive?

  Yes

  No

  N/A

• Workload boring and repetitive?

  Yes

  No

  N/A

• 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?

  up

  down

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

  front

  back

  side

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

• If the incident involves manual handling:

• Were work 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 movement used?

  Yes

  No

  N/A

• Action involved:

  Select reaching bending stooping sitting kneeling twisting pushing pulling lifting catching lowering carrying

  • reaching
  • bending
  • stooping
  • sitting
  • kneeling
  • twisting
  • pushing
  • pulling
  • lifting
  • catching
  • lowering
  • carrying

• Weight of object?
  

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

• Height of load?

Completed by the person or persons involved

• Full name

• Signature

  Sign