PART 1: INSTRUCTIONS

  • To be completed by the person or persons directly involved.

  • The person reporting is to follow the Incident and Accident Policy. Then complete this report and provide it to the workshop within one hour or as soon as practical.

Section A: Personal and Incident Details

  • Title(E.g. Miss,Mr,Mrs,Dr,Dra):

  • Last Name:

  • Other Name/s:

  • Date of Birth:

  • Are you?

  • Sex:

  • Occupation:

  • Email Address:

  • Phone (W):

  • Phone (H):

  • Home Address:
  • Date and Time of Incident:

  • Location of the Incident:
  • How did the incident happen?

  • Signed by:

  • Name of Witness/es:

  • Phone of Witness/es:

Section B: Supervisor or Workshop Manager Notification

  • Name of WHS Manager:

  • Date and time of incident:

  • Signed by:

  • Phone of WHS Manager:

  • Name of Supervisor:

  • Date and time of incident:

  • Signed by:

  • Phone of Supervisor:

Section C: Injury Details (If applicable) Use this section to also report workplace disease

  • Type of injury or disease (e.g. burn)

  • Part/s of the body affected:

  • Date and time when symptoms noticed:

  • Was medical treatment given?

  • First Aid

  • Nurse

  • Doctor

  • Hospital

  • Name of person giving initial treatment:

  • Date and time initial treatment given:

  • Time lost due to injury?

  • How many hours/days?

PART 2: INVESTIGATION CHECKLIST AND ACTION REPORT FORM

  • Incident/ Injury: How do you think the accident/ injury happened and what were you doing at the time?

Investigation Checklist:

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

  • How long had you been working on this task?

  • Is this task part of your normal duties?

  • Have you been instructed/ trained in this task?

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

  • Are there any other factors involved (e.g. management, the work environment, equipment, maintenance, individual)?

  • Management

  • The Work Environment

  • Equipment

  • Maintenance

  • Individal

  • Other

  • Please specify:

  • What do you think could have been done to prevent this incident from occurring?

  • Any other comments or observations?

  • Please answer the most appropriate response/s:

  • What sort of incident/ injury occured?

  • If you selected Other please specify:

  • Type of injury:

  • If you selected Other please specify:

  • Safe Work Method Statements followed?

Identification of equipment/ object/ insect involved:

  • Equipment in good condition?

  • Date of last service of equipment:

  • Appropriate safety equipment (PPE) used?

  • Lighting adequate?

  • Housekeeping issues contributed?

  • Surface type:

  • If you selected Other please specify:

  • Type of shoes worn:

  • If you selected Other please specify:

  • Workload excessive?

  • Workload boring and repetitive?

  • Is the injury was a slip or trip?

  • What were you doing that time of slip ot trip?

  • If you selected Other please specify:

  • Going up

  • Going down

  • Which part of the body did you fall?

  • Were you carrying something at that time

  • If yes please specify:

  • Is the incident involves manual handling?

  • Were work items within easy reach?

  • Ergonomic equipment available?

  • Was the equipment being used correctly?

  • Repetitive and/or forceful movements used?

  • Action involved:

  • If you selected Other please specify:

  • 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 hierarchy of control should be used to assist with the prevention of future similar injuries. The 'hierarchy of control' depicts the most to the lease effective methods.

  • Risk Control Options

  • Elimination- do you have to do the task?

  • Substitution- is there another way you can do the task?

  • Action required:

  • By whom:

  • By when:

  • Engineering- can we engineer a way to make the job safer?

  • Action required:

  • By whom:

  • By when:

  • Administration- can you improve work practice? E.g. limit time of exposure.

  • Action required:

  • By whom:

  • By when:

  • What are the Personal Protective Equipment (PPE) needed?/ Action required.

  • By whom:

  • By when:

  • Action required:

  • By whom:

  • By when:

  • Date feedback provided to person reporting the injury/ incident:

  • Signed by:

  • Phone:

  • Position:

  • Office Use Only (Health and Safety Recommendations)

  • Date part 2 received:

  • Date Completed:

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