Incident Report 2017

• Safety Culture

• Safety Culture

• Conducted on

  Date

• Prepared by

Part 1. INSTRUCTIONS

Section A. Personal and Incident Details

• Last name:

• Other name/s:

• Date of birth:

  Date

• Gender:

  Male

  Female

• Occupation:

• Email:

• Contact details:

• Address:
  Address

• Date and Time of injury:

  Date
• Incident location:
  Address

• Incident description:

• Signed:

  Sign

• Name of witness/es:

• Phone:

Section B. Supervisor or Workshop Manager Notification

• Name of WHS Manager:

• Date and time of incident:

  Date

• Phone:

• Signed:

  Sign

• Name of Supervisor:

• Date and time of incident:

  Date

• Phone:

• Signed:

  Sign

Section C. Injury Details

• Type of injury or disease:

• Part/s of the body affected:

• Date and time when symptoms noticed:

  Date

• Was medical treatment given?

  Yes

  No

  N/A

• Name of person giving initial treatment:

• Date and time initial tratment given:

  Date

• Time lost due to injury?

  Yes

  No

  N/A

• How many hours/days?

Part 2. INVESTIGATION CHECKLIST AND ACTION REPORT FORM

• How did the incident happen and what were you doing at that time?

Investigation Checklist:

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

• How long had you been working on this task?

• Is this task part of your normal duties?

  Yes

  No

  N/A

• Have you been trained in this task?

  Yes

  No

  N/A

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

• Are there any other factors involved?

  Yes

  No

  N/A

• What could have been done to prevent the incident?

• Any comments or observations?

• What sort of incident occured?

  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

• Type of injury:

  Select Sting Bite Kick Puncture Strain Sprain Hazardous substances Slip Trip Fall Other

  • Sting
  • Bite
  • Kick
  • Puncture
  • Strain
  • Sprain
  • Hazardous substances
  • Slip
  • Trip
  • Fall
  • Other

• Safe Work Method Statements followed?

  Yes

  No

  N/A

Identification of equipment/object/insect involved:

• 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

• Type of shoes worn:

  Select Open Closed Boots High heels Sandals None Other

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

• Workload excessive?

  Yes

  No

  N/A

• Workload boring and repetitive?

  Yes

  No

  N/A

If it was a slip or trip:

• Height of fall/slip/trip?

• Were you running/walking/turning a corner/jumping/other?

  Yes

  No

  N/A

• If stairs - going up or going down?

  Going up

  Going down

• Did you fall on your front/back/side?

  Front

  Back

  Side

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

If the incident involves manual handling:

• Were work items within easy reach?

  Yes

  No

  N/A

• Egonomic 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?

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

• Height of load?

Part 3: TO BE COMPLETED BY WHS MANAGER

• Investigator's comments and observations from part 2:

RECOMMENDATIONS. A hierarcy of control should be used to assist with the prevention of future similar injuries. The hierarchy of control depicts the most of the least effective methods.

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

Risk Control Options

Elimination - do you have to do the task?

• Action Required:

• By Whom:

• By When:

Substitution - Is there another way you can do the task?

• Action Required:

• By Whom:

• By When:

Administration - Can you improve work practices? E.g limit time of exposure.

• Action Required:

• By Whom:

• By When:

Personal Protective Equipment (PPE)

• Action Required:

• By Whom:

• By When:

• Date feedback provided to person reporting the incident:

  Date

• Signed:

  Sign

• Position:

• Date:

  Date

• Office Use Only (Health and Safety Recommendations)

• Date Part 2 received:

  Date

• Date completed:

  Date