Lariza G. Dela Pena

• Document No.

• Conducted on

  Date

• Prepared by

• Client / Site

• 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:

  Date

• Are you?

  Relevant Worker

  Contractor

  Visitor

• Sex:

  Male

  Female

• Occupation:

• Email Address:

• Phone (W):

• Phone (H):

• Home Address:
  Address

• Date and Time of Incident:

  Date
• Location of the Incident:
  Address

• How did the incident happen?

• Signed by:

  Sign

• Name of Witness/es:

• Phone of Witness/es:

Section B: Supervisor or Workshop Manager Notification

• Name of WHS Manager:

• Date and time of incident:

  Date

• Signed by:

  Sign

• Phone of WHS Manager:

• Name of Supervisor:

• Date and time of incident:

  Date

• Signed by:

  Sign

• 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:

  Date

• Was medical treatment given?

  Yes

  No

• First Aid

• Nurse

• Doctor

• Hospital

• Name of person giving initial treatment:

• Date and time initial treatment given:

  Date

• Time lost due to injury?

  Yes

  None

• How many hours/days?

• 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?

  Yes

  No

  N/A

• Have you been instructed/ trained in this task?

  Yes

  No

  N/A

• 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)?

  Yes

  None

• 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?

  Select Manual Handling Occupational Overuse Syndrome (OOS) Cuts Bruises Burns Falls Slips Trips Vehicles Bicycles Hazardous substances Insects Animals Foreign Body Plant Stress Other

  • Manual Handling
  • Occupational Overuse Syndrome (OOS)
  • Cuts
  • Bruises
  • Burns
  • Falls
  • Slips
  • Trips
  • Vehicles
  • Bicycles
  • Hazardous substances
  • Insects
  • Animals
  • Foreign Body
  • Plant
  • Stress
  • Other

• If you selected Other please specify:

• Type of injury:

  Select Sting Bite Kick Puncture Strain Hazardous substance Slip Trip Fall Other

  • Sting
  • Bite
  • Kick
  • Puncture
  • Strain
  • Hazardous substance
  • Slip
  • Trip
  • Fall
  • Other

• If you selected Other please specify:

• 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 Tile Grass Dry Wet Damaged Torn Sand Footpath Carpet Gravel Rocks Road Other N/A

  • Tile
  • Grass
  • Dry
  • Wet
  • Damaged
  • Torn
  • Sand
  • Footpath
  • Carpet
  • Gravel
  • Rocks
  • Road
  • Other
  • N/A

• If you selected Other please specify:

• Type of shoes worn:

  Select Open Closed Boots High heels Sandals None Other

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

• If you selected Other please specify:

• Workload excessive?

  Yes

  No

  N/A

• Workload boring and repetitive?

  Yes

  No

  N/A

• Is the injury was a slip or trip?

  Yes

  No

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

  Select Running Walking Turning a corner Jumping Using stairs Other

  • Running
  • Walking
  • Turning a corner
  • Jumping
  • Using stairs
  • Other

• If you selected Other please specify:

• Going up

• Going down

• Which part of the body did you fall?

  Front

  Back

  Side

  N/A

• Were you carrying something at that time

  Yes

  None

• If yes please specify:

• Is the incident involves manual handling?

  Yes

  No

• Were work items within easy reach?

  Yes

  No

  N/A

• Ergonomic 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 Other

  • Reaching
  • Bending
  • Stooping
  • Sitting
  • Kneeling
  • Twisting
  • Pushing
  • Pulling
  • Lifting
  • Catching
  • Lowering
  • Carrying
  • Other

• If you selected Other please specify:

• Weight of object?

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

• Height of load?

• 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?

  Yes

  No

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

  Yes

  None

• Action required:

• By whom:

• By when:

  Date

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

  Yes

  No

• Action required:

• By whom:

• By when:

  Date

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

  Yes

  No

• Action required:

• By whom:

• By when:

  Date

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

• By whom:

• By when:

  Date

• Action required:

• By whom:

• By when:

  Date

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

  Date

• Signed by:

  Sign

• Phone:

• Position:

• Office Use Only (Health and Safety Recommendations)

• Date part 2 received:

  Date

• Date Completed:

  Date