Title Page
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
PERSONAL DETAILS AND INCIDENT DETAILS
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PLEASE PROVIDE ALL RELEVANT INFORMATION REGARDING THE INJURED PERSON
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PERSONAL DETAILS
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FULL NAME
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DATE OF BIRTH
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SEX
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ADDRESS
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CONTACT NUMBER (PHONE/MOBILE)
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EMAIL ADDRESS
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OCCUPATION
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ARE YOU?
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INCIDENT DETAILS
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DATE AND TIME OF ACCIDENT
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HOW DID THE INCIDENT HAPPEN?
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LOCATION OF INCIDENT
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NAME OF WITNESS/ES:
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WAS MEDICAL TREATMENT GIVEN?
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PART/S OF THE BODY AFFECTED:
INVESTIGATION CHECKLIST AND ACTION REPORT FORM
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HOW DO YOU THINK THE INJURY HAPPENED?
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WHAT WERE YOU DOING THAT TIME?
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INVESTIGATION CHECKLIST
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HOW LONG HAD YOU BEEN WORKING PRIOR TO THE INJURY?
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HOW LONG HAD YOU BEEN WORKING ON THIS TASK?
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IS THIS TASK PART OF YOUR NORMAL DUTY?
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HAVE YOU BEEN TRAINED IN THIS TASK?
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ARE THERE ANY OTHER FACTORS INVOLVED? (E.G MANAGEMENT, EQUIPMENT, MAINTENANCE, INDIVIDUAL)
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WHAT DO YOU THINK YOU COULD HAVE DONE TO AVOID THIS INCIDENT TO OCCUR?
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SAFE WORK METHOD FOLLOWED?
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IF IT WAS A SLIP OF TRIP:
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HEIGHT OF FALL/SLIP/TRIP?
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WERE YOU RUNNING/WALKING/TURNING A CORNER/JUMPING OR OTHER? PLEASE SPECIFY.
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IF STAIRS, GOING UP/DOWN?
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DID YOU FALL ON YOUR FRONT/BACK/SIDE?
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WHAT WERE YOU CARRYING (IF ANYTHING) AT THE TIME?
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IF INCIDENT INVOLVES MANUAL HANDLING:
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WERE WORK ITEMS WITHIN EASY REACH?
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ERGONOMIC EQUIPMENT AVAILABLE?
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WAS THE EQUIPMENT BEING USED CORRECTLY?
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REPETITIVE AND/OR FORCEFUL MOVEMENTS USED?
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ANY ACTIONS INVOLVED?
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WEIGHT OF OBJECT:
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DISTANCE CARRIED/POSITION OF OBJECT MOVED FROM/TO?
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HEIGHT OF LOAD?
SUPERVISOR OR WORKSHOP MANAGER NOTIFICATION
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TO BE COMPLETED BY THE WHS MANAGER
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INVESTIGATOR'S COMMENTS AND OBSERVATIONS:
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NAME OF SUPERVISOR:
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DATE
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SIGNATURE
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NAME OF WHS MANAGER:
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DATE
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SIGNATURE
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RECOMMENDATIONS: A HIERARCHY OF CONTROL SHOULD BE USED TO ASSIST THE PREVENTION OF FUTURE SIMILAR INJURIES. THE 'HIERARCHY OF CONTROL' DEPICTS THE MOST TO THE LEAST EFFECTIVE METHODS.
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THIS IS THE MOST IMPORTANT PART OF THE INVESTIGATION PROCESS. DO NOT LEAVE BLANK.
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ELIMINATION- DO YOU HAVE TO DO THE TASK?
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LEAVE COMMENTS:
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SUBSTITUTION- IS THERE ANOTHER WAY YOU CAN DO THE TASK?
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LEAVE COMMENTS:
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ENGINEERING- CAN YOU ENGINEER A WAY TO MAKE THE JOB SAFER?
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LEAVE COMMENTS:
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ADMINISTRATION- CAN YOU IMPROVE WORK PRACTICES? (E.G LIMIT TIME OF EXPOSURE)
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PERSONAL PROTECTIVE EQUIPMENT:
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LEAVE COMMENTS:
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ACTION REQUIRED:
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DATE FEEDBACK PROVIDED TO PERSON REPORTING THE INCIDENT:
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PRINT NAME:
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SIGNATURE:
