Incident/Injury Report Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• The person reporting is to follow the Incident and Accident Policy. Then complete this report and provide it to the
  workshop manager within one hour or as soon as practical.

I. PERSONAL AND INCIDENT DETAILS

• Full Name

• Date of Birth:

  Date

• Are you?

  Relevant Worker

  Contractor

  Visitor

• Sex

  Male

  Female

• Occupation

• Email address:

• Phone (W):

• Phone (H):

• Date and Time of Incident:

  Date
• Location of incident:
  Address

• How did the incident happen?

• Signed:

  Sign

• Date:

  Date

II. SUPERVISOR or WORKSHOP MANAGER NOTIFICATION

• Name of WHS Manager:

• Date and time of incident:

  Date

• Signed:

  Sign

• Date:

  Date

• Phone:

• Name of Supervisor:

• Date and time of incident:

  Date

• Signed:

  Sign

• Date:

  Date

• Phone:

INJURY DETAILS

• Type of injury or disease?

  Select Burn Brusing Sprain Strain Fracture Other

  • Burn
  • Brusing
  • Sprain
  • Strain
  • Fracture
  • Other

• Please specify:

• Part/s of the body affected:

  Select Head Eye Ear Nose Mouth Neck Upper Back Lower Back Chest Shoulder Arm Forearm Elbow Hand Wrist Finger Abdomen Leg Thigh Knee Foot Ankle Toe Heel Other

  • Head
  • Eye
  • Ear
  • Nose
  • Mouth
  • Neck
  • Upper Back
  • Lower Back
  • Chest
  • Shoulder
  • Arm
  • Forearm
  • Elbow
  • Hand
  • Wrist
  • Finger
  • Abdomen
  • Leg
  • Thigh
  • Knee
  • Foot
  • Ankle
  • Toe
  • Heel
  • Other

• Please specify:

• Location of Affected Body Part?

  Right Eye

  Left Eye

  Both Eyes

• Location of Affected Body Part?

  Left Ear

  Right Ear

  Both Ears

• Location of Affected Body Part?

  Left Shoulder

  Right Shoulder

  Both Shoulders

• Location of Affected Body Part?

  Left Arm

  Right Arm

  Both Arms

• Location of Affected Body Part?

  Left Knee

  Right Knee

  Both Knees

• Location of Affected Body Part?

  Select Thumb Index Finger Middle Finger Ring Finger Baby Finger or "Pinky"

  • Thumb
  • Index Finger
  • Middle Finger
  • Ring Finger
  • Baby Finger or "Pinky"

• Location of Affected Body Part?

  Left Forearm

  Right Forearm

  Both Forearms

• Location of Affected Body Part?

  Left Elbow

  Right Elbow

  Both Elbows

• Location of Affected Body Part?

  Left Wrist

  Right Wrist

  Both Wrists

• Location of Affected Body Part?

  Left Hand

  Right Hand

  Both Hands

• Location of Affected Body Part?

  Left Leg

  Right Leg

  Both Legs

• Location of Affected Body Part?

  Left Foot

  Right Foot

  Both Feet

• Location of Affected Body Part?

  Left Ankle

  Right Ankle

  Both Ankles

• Location of Affected Body Part?

  Left Toe

  Right Toe

  Both Toes

• Location of Affected Body Part?

  Left Heel

  Right Heel

  Both Heels

• Location of Affected Body Part?

  Left Thigh

  Right Thigh

  Both Thighs

• Date and time when symptoms noticed:

  Date

• Was medical treatment given?

  No

  First Aid

  Nurse

  Doctor

  Hospital

• Name of person giving initial treatment:

• Date and time initial treatment given:

  Date

• Time lost due to injury?

  Yes

  No

• How many hours?

• How many days?

III. INVESTIGATION CHECKLIST AND ACTION REPORT FORM

• How did the injury happen?

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

  Select weeks 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years and above

  • weeks
  • 1 month
  • 2 months
  • 3 months
  • 4 months
  • 5 months
  • 6 months
  • 7 months
  • 8 months
  • 9 months
  • 10 months
  • 11 months
  • 1 year
  • 2 years
  • 3 years
  • 4 years
  • 5 years and above

• How long had you been working on this task?

  Select weeks 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years and above

  • weeks
  • 1 month
  • 2 months
  • 3 months
  • 4 months
  • 5 months
  • 6 months
  • 7 months
  • 8 months
  • 9 months
  • 10 months
  • 11 months
  • 1 year
  • 2 years
  • 3 years
  • 4 years
  • 5 years and above

• Is this task part of your normal duties?

  Yes

  No

  N/A

• Have you been instructed / trained in this task?

  Yes

  No

  N/A

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

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

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

• Please select the most appropriate response/s:

• What sort of incident / injury occurred?

  Select Manual Handling Occupational Overuse Syndromes (OOS) Cuts Bruises Burns Falls Slips Trips Vehicles Bicycles Hazardous Substances Insects Animals Foreign body Plant Stress Other

  • Manual Handling
  • Occupational Overuse Syndromes (OOS)
  • Cuts
  • Bruises
  • Burns
  • Falls
  • Slips
  • Trips
  • Vehicles
  • Bicycles
  • Hazardous Substances
  • Insects
  • Animals
  • Foreign body
  • Plant
  • Stress
  • Other

• Please specify:

• 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

• Please specify:

• Safe Work Method Statements followed?

  Yes

  No

  N/A

• Equipment/object/insect involved?

  Yes

  No

  N/A

• Equipment in good condition?

  Yes

  No

  N/A

• Date of last service of equipment:

  Date

• Appropriate safety equipment (PPE) used?

  Yes

  No

  N/A

• Lighting adequate?

  Yes

  No

  N/A

• Housekeeping issues contributed?

  Yes

  No

  N/A

• 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

• Please specify:

• Type of shoes worn:

  Select Open Closed Boots High heels Sandals None Other

  • Open
  • Closed
  • Boots
  • High heels
  • Sandals
  • None
  • Other

• Please specify:

• 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 / slip / trip in feet?

• Were you:

  Select Running Walking Turning a corner Jumping Other

  • Running
  • Walking
  • Turning a corner
  • Jumping
  • Other

• Please specify:

• If stairs:

  Going up

  Going down

  N/A

• Did you fall on your:

  Front

  Back

  Side

• What were you carrying (if anything) at the time?

• If the incident involves manual handling?

  Yes

  No

  N/A

• 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

• Repetitive and/or forceful movements 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 in kgs?

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

• Height of load in feet?

• Investigator’s comments and observations:

• Attach any relevant photos

  Media

• This is the most important part of the investigation process! Do not leave blank.

• Elimination – do you have to do the task?

  Yes

  No

• Action required:

• By Whom?

• By When?

• Substitution – is there another way you can do the task?

  Yes

  No

• Action required:

• By Whom?

• By When?

• Engineering – can you engineer a way to make the job safer?

  Yes

  No

• Action required:

• By Whom?

• By When?

• Administration – can you improve work practices? E.g. limit time of exposure.

  Yes

  No

• Action required:

• By Whom?

• By When?

• Personal Protective Equipment (PPE)

  Yes

  No

• Action required:

• By Whom?

• By When?

• Date feedback provided to person reporting the injury/incident:

  Date

• Signed:

  Sign

• Position:

• Ph.:

• Date:

  Date

• Health and Safety Recommendations:

• Date received:

  Date

• Date Completed:

  Date