Injury, Accident, Incident Report

• Centre / Site

• Conducted on

  Date

• Incident report prepared by

• Job title and department

• Do be courteous always
  Do provide Realm contact details Do obtain photos of incidents and surrounding area
  Do obtain witness statements and contact details Do Not accept liability Do Not make a judgement on who is at fault.

Personal Details

• Incident Type

  Select Near Miss Unsafe Act Minor Injury Serious Injury Major Injury Fatality Environmental (Spill / Gas / Flood / Fire) Anti Social Behavior Security Related Theft Structural or fabric damage Other

  • Near Miss
  • Unsafe Act
  • Minor Injury
  • Serious Injury
  • Major Injury
  • Fatality
  • Environmental (Spill / Gas / Flood / Fire)
  • Anti Social Behavior
  • Security Related
  • Theft
  • Structural or fabric damage
  • Other

• Name of injured / affected person(s)

• Gender

  Select Male Female Intersex Trans Cisgender Two-Spirit Third Sex Agender Non-confirming Genderqueer Personal Eunuch Other

  • Male
  • Female
  • Intersex
  • Trans
  • Cisgender
  • Two-Spirit
  • Third Sex
  • Agender
  • Non-confirming
  • Genderqueer
  • Personal
  • Eunuch
  • Other

• Address of injured / affected person(s)

• Contact Number

• Date of birth of injured / affected person(s)

  Date

• Were any utilities affected?

  Gas

  Water

  Electricity

  Other

Detail description of the event:

• undefined

Incidents slip, trip or fall related

• Date and time incident was reported.

  Date

• Location of incident. (Specify site location)

• To whom was the incident reported?

• Weather conditions? (for incidents in open areas)

  Select Sunny / Clear / Dry Rainy Cloudy Windy Snow Icy

  • Sunny / Clear / Dry
  • Rainy
  • Cloudy
  • Windy
  • Snow
  • Icy

• Lighting / visibility conditions?

  Good

  Fair

  Poor

  N/A

• Wet floor sign present?

  Yes

  No

  N/A

• Floor Condition?

  Good

  Fair

  Poor

  N/A

• Was the injured person wearing appropriate footwear?

  Yes

  No

  N/A

• Was the injured person carrying anything at the time of the incident?

  Nothing in hands

  In one hand

  In both hands

  Other

• Damaged clothing or footwear?

  Yes

  No

  N/A

• Was the incident captured by CCTV?

  Yes

  No

  N/A

• CCTV Reference or file name?

• Was there any witness(es)? If yes, provide name(s) and contact details.

  Yes

  No

  N/A

• Name and contact of witness 1

• Statement of witness 1

• Signature of witness 1

  Sign

• Name and contact of witness 2

• Statement of witness 2

• Signature of witness 2

  Sign

• Name and contact of witness 3

• Statement of witness 3

• Signature of witness 3

  Sign

Details of injury, if applicable

• Describe injury.

• How did the injury/damage occur and what caused it?

• What was the injured/affected person(s) actually doing at the time of the accident/incident?

• Describe body parts affected.

• Detail any first-aid or medical treatment administered. (Provide names)

• Details of first-aid supplies used.

• Details of relevant existing conditions.

• Details of relevant medications.

• First Aider(s) name and call signs

• If no treatment provided, why?

  Select Person did not required treatment Person refused treatment Person went straight to hospital Accident was reported at a later date Person leave site in ambulance Person make own way to hospital Person not require ambulance or treatment and continued shopping Refuse an ambulance or transport to hospital Other

  • Person did not required treatment
  • Person refused treatment
  • Person went straight to hospital
  • Accident was reported at a later date
  • Person leave site in ambulance
  • Person make own way to hospital
  • Person not require ambulance or treatment and continued shopping
  • Refuse an ambulance or transport to hospital
  • Other

Police

• Police called / informed?

  Yes

  No

  N/A

• Time of the call to Police?

  Date

• Time Police attended?

  Date

• Police unit attended shoulder number?

• Police crime / incident reference number?

Ambulance / Paramedics

• Ambulance / Paramedics called?

  Yes

  No

  N/A

• Time of the call to Ambulance / Paramedics?

  Date

• Time Ambulance / Paramedics attended?

  Date

• Ambulance / Paramedics unit shoulder number?

Fire Brigade

• Fire Brigade called?

  Yes

  No

  N/A

• Time of the call to Fire Brigade?

  Date

• Time Fire Brigade attended?

  Date

• Fire Brigade unit shoulder number?

Events involving property damage

• Property / building fabric damage:

• Photo of damage.

  Media

• Was center machinery / equipment involved (compactors / lifts / escalators / MEWP)?

  Yes

  No

  N/A

• Was contractor / delivery or third party machinery, vehicle or equipment involved?

  Yes

  No

  N/A

• Vehicle ID:

• Detailed description of incident. (Include environmental conditions at time of incident)

• Environmental photo:

  Media

• Immediate (Direct Causes):

• Direct cause photo:

  Media

Events involving Fire or Gas

• What type of incident occurred?

  Fire event actual

  Fire event suspected

  Gas leak actual

  Gas leak suspected

• Did the alarm / alert system activated?

  Yes

  No

  N/A

• What caused the activation?

• Did center evacuate?

  Yes

  No

  N/A

• If there was an evacuation, what time were people allowed to return?

  Date

Analysis

• Contributing (underlying) Factors:

• Contributing factors photo:

  Media

• Corrective Action (Include detail description of action and person(s) responsible for actions)

• What could have potentially happened?

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

Additional notes if required

• Notes

• Date & Time

  Date

• Name and signature

  Sign