Injury Report

• Name of Injured employee

• Injured employees Date of Birth (DOB)

  Date

• Injured employees contact number.

• Injured employees job title

• Project (inc. project no.)

• Address of site where injury occured

• Date and Time of Injury

  Date

• Injury Report Completed by (name)

Injury Details

• Add a photo of the Site location where injury occurred

  Media

• How did the injury occur? (How, Why and Contribution Factors)

• Enter a description of the injury

• Add a photo of the injury

  Media

• Was FIRST AID treatment administered?

  Yes

  No

• Details of treatment given

• Who provided First Aid? (Name)

• Was MEDICAL TREATMENT required?

  Yes

  No

• Details of treatment given

• Who provided Medical Treatment?

• Did the employee continue working?

  Yes

  No

• Provided details of why the employee did not continue working.

• Was protective equipment required?

  Yes

  No

• What protective equipment was required?

• Add photo of Protective Equipment

  Media

• Was Protective Equipment supplied?

  Yes

  No

• What has protective equipment not been supplied? And what has been done to supply it?

• Was Protective Equipment being worn?

  Yes

  No

• Why was protective equipment not being worn / used?

• Was a Safe Work Method Statement Required?

  Yes

  No

• Was a SWMS Prepared?

  Yes

  No

• Was the SWMS being followed?

  Yes

  No

Supervisor (Mandatory)

• Supervisor Name

• Date and Time of Notification to supervisor

  Date

• Method

  In Person

  Phone

  Email

Project Manager (Mandatory)

• Project Managers Name

• Date and Time of Notification to Project Manager

  Date

• Method

  In Person

  Phone

  Email

QSE (if required) - Immediately for any injury requiring external medical treatment or emergency services.

• QSE Managers Name

• Date and Time of Notification to QSE Manager

  Date

• Method

  In Person

  Phone

  Email

HR (if required) - Immediately for any injury requiring external medical treatment or emergency services.

• HR Managers Name

• Date and Time of Notification to HR Manager

  Date

• Method

  In Person

  Phone

  Email

• Use this section to record details of any witnesses to the injury and record statements if necessary.

Witness

• Name of Witness

• Company

• Contact Number

• Statement of events

• Signature

  Sign

• Use this section to record any immediate actions taken and / or any corrective / preventative actions (CAPA) taken to prevent the possibility of a similar accident occurring.

• Enter details of any immediate actions taken to prevent a similar accident occurring.

• Enter details of any corrective or preventative actions to be taken to prevent the possibility of a similar accident occurring.