Initial Incident Investigation

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Type of Incident

• Choose

  Select First Aid Injury Near Miss Medical Treated Injury Environmental Incident Rail Safety Cat A Rail Safety Cat B Major Incident Incident causing damage

  • First Aid Injury
  • Near Miss
  • Medical Treated Injury
  • Environmental Incident
  • Rail Safety Cat A
  • Rail Safety Cat B
  • Major Incident
  • Incident causing damage

• What treatment was provided?

• Who administered the treatment?

• What body part was injured?

  Select Finger Thumb Right hand Left hand Right elbow Left elbow Left arm Right arm Left shoulder Right shoulder Neck Head Right eye Left eye Face Left knee Right knee Left leg Right leg Left foot Right foot Lower back Upper back

  • Finger
  • Thumb
  • Right hand
  • Left hand
  • Right elbow
  • Left elbow
  • Left arm
  • Right arm
  • Left shoulder
  • Right shoulder
  • Neck
  • Head
  • Right eye
  • Left eye
  • Face
  • Left knee
  • Right knee
  • Left leg
  • Right leg
  • Left foot
  • Right foot
  • Lower back
  • Upper back

• Was any of the below involved of being used when incident occurred?

• Rolling stock

• Drug and alcohol testing required immediately.

• Mobile plant equipment eg. Forklift, EWP, shunt tractors and overhead cranes.

• Drug and alcohol testing required immediately.

Details of Person/s Injured or Involved

• Name/s

• Position Title

  Select Trades Assistant Trades person Team Leader Zone Leader Manager Technician Office Staff Visitor Superintendent

  • Trades Assistant
  • Trades person
  • Team Leader
  • Zone Leader
  • Manager
  • Technician
  • Office Staff
  • Visitor
  • Superintendent

• Employment Status

  Select Full Time Part Time Casual Apprentice Contractor Visitor

  • Full Time
  • Part Time
  • Casual
  • Apprentice
  • Contractor
  • Visitor

Details of Person/s Injured or Involved

• Name/s

• Position Title

  Select Trades Assistant Trades person Team Leader Zone Leader Manager Technician Office Staff Visitor Superintendent

  • Trades Assistant
  • Trades person
  • Team Leader
  • Zone Leader
  • Manager
  • Technician
  • Office Staff
  • Visitor
  • Superintendent

• Employment Status

  Select Full Time Part Time Casual Apprentice Contractor Visitor

  • Full Time
  • Part Time
  • Casual
  • Apprentice
  • Contractor
  • Visitor

Details of Person/s Injured or Involved

• Name/s

• Position Title

  Select Trades Assistant Trades person Team Leader Zone Leader Manager Technician Office Staff Visitor Superintendent

  • Trades Assistant
  • Trades person
  • Team Leader
  • Zone Leader
  • Manager
  • Technician
  • Office Staff
  • Visitor
  • Superintendent

• Employment Status

  Select Full Time Part Time Casual Apprentice Contractor Visitor

  • Full Time
  • Part Time
  • Casual
  • Apprentice
  • Contractor
  • Visitor

Details of Person/s Injured or Involved

• Name/s

• Position Title

  Select Trades Assistant Trades person Team Leader Zone Leader Manager Technician Office Staff Visitor Superintendent

  • Trades Assistant
  • Trades person
  • Team Leader
  • Zone Leader
  • Manager
  • Technician
  • Office Staff
  • Visitor
  • Superintendent

• Employment Status

  Select Full Time Part Time Casual Apprentice Contractor Visitor

  • Full Time
  • Part Time
  • Casual
  • Apprentice
  • Contractor
  • Visitor

Incident Details

• Time & Date Of Incident

  Date

• Time & Date Reported

  Date

• Reported to:

• Position Title

  Select Trades Assistant Trades person Team Leader Zone Leader Manager Technician Office Staff Visitor Superintendent

  • Trades Assistant
  • Trades person
  • Team Leader
  • Zone Leader
  • Manager
  • Technician
  • Office Staff
  • Visitor
  • Superintendent

• Reported by:

• Position Title

  Select Trades Assistant Trades person Team Leader Zone Leader Manager Technician Office Staff Visitor Superintendent

  • Trades Assistant
  • Trades person
  • Team Leader
  • Zone Leader
  • Manager
  • Technician
  • Office Staff
  • Visitor
  • Superintendent

• Description Of Event

• Why did this happen?

• What controls have been put in place since incident occurred?

• Take Photos

  Media

Immediate Actions

• Describe immediate actions taken:

• Was Drug and Alcohol testing required?

  Yes

  No

  N/A

• Details if 'Yes'

Controls Put In Place

Analysis of Contributory Factors

• Failed defences (absent or failed)

• Comments

• Individual / team actions (error or violation)

• Comments

• Task / environment conditions (contributor)

• Comments

• Organisational factors types

• Comments