McPherson Tree Care Incident Record

• Location

• Type of Event

  Select Injury Illness Medical Event Near Miss/Close Call Environmental Notifiable Event

  • Injury
  • Illness
  • Medical Event
  • Near Miss/Close Call
  • Environmental
  • Notifiable Event

Persons Involved

Directly Affected

• Name

• Category

  Employee

  Visitor

  Contractor

• Is contracted as

  Full-time

  Part-time

  Temporary

  Seasonal

• Position

• Supervisor/Manager Name

• Duration of employment (approx.)

• What reason is visitor present at the time of event

  Select Courier Delivering packages Customer Client Friend/Family member Utility/Maintenance Salesperson Other

  • Courier
  • Delivering packages
  • Customer
  • Client
  • Friend/Family member
  • Utility/Maintenance
  • Salesperson
  • Other

• Describe details of volunteer work, duration, frequency etc

• Has volunteer been inducted

  Yes

  No

  N/A

• Describe details of work, duration, frequency etc

• Had Contractor been inducted

  Yes

  No

  N/A

• How were you directly affected? In what capacity was your role in this event?

  Select Injured Impaired Mental Health Adversely Affected Ill Assisting with first aid/medical treatment Assisting with managing event (traffic, cleanup) Emergency team member

  • Injured
  • Impaired
  • Mental Health Adversely Affected
  • Ill
  • Assisting with first aid/medical treatment
  • Assisting with managing event (traffic, cleanup)
  • Emergency team member

• Contact Phone Number

• Email Address

• Address

• Type of address

  Physical

  Postal

• Age

• Other notes you that may be of importance, ie Impaired Person

• Continue documenting other Directly Affected Persons or Witnesses details. Once you have the details of all those involved, move on to the next section "The Event"

The Event

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• Describe the events that occurred

• Name of person it was reported by

• Category of person

  Employee

  Visitor

  Contractor

• To whom was the incident reported?

• Position

Treatment

• What treatment was administered at time of event?

  Select First-Aid Medical None Emergency Services were required

  • First-Aid
  • Medical
  • None
  • Emergency Services were required

• Provide details

• Were medicines given?

  Yes

  No

  N/A

• Provide details if known (ie Name(s), dosage(s), time given such immediately etc)

Ongoing Treatment

• Was further medical treatment required?

  Yes

  No

  N/A

• Provide details, if known of treatment centre, treatment, outcome etc

• Once all details of ongoing treatment has been provided move onto next section "Damage to Property"

Damage to Property/Vehicle

• Property Damage:

  N/a

  Vehicle

  Equipment

  Private Property

  Plant

• Identifying features ie Make/Model, colour, year

• Registration Plate

• Provide as many details as possible ie address, clothing

• Description ie Make/Model, Machine ID

• Approx. age if known

• Severity of damage

  None

  Minor

  Serious

  Major

• Description of damage

• Estimated cost of damage:

• Photo of damage.

  Media

Post Event

Corrective Actions

• What corrective actions need to be actioned to reduce the risk of event reoccurring? Provide details

Worksafe

• Tick if Worksafe needs to be notified

• Have the been notified already?

  Yes

  No

  N/A

• When

  Date

• Name of person who notified Worksafe

• Position

• Is there further follow up actions required by Worksafe?

  Yes

  No

  N/A
Training required

• Details of training to be carried out

Admin Follow Up Tasks

• Incident Event Register updated

• Does this require an Investigation Record Form to be completed?

  Yes

  No

  N/A

• Does Hazard Register need to be updated?

• Event communicated to team

  Yes

  Scheduled

  Other

• Provide details ie Email, TB Meeting (include dates in case evidence is required)

• Provide details

Return to work

• Provide details of return to work plan

  Modified duties

  Full recovery, normal duties

  Work from home

  To be determined

  Other

• Has a Return to Work Plan been completed?

  Yes

  No

  N/A

Signatures

• Please ensure that signatures are obtained from all individuals referenced in this report.

Add signatures here.

• By signing, you acknowledge that you have read and reviewed the document and confirm its accuracy and truthfulness.

• Name

  Sign

• Yes

  No

  N/A

Additional Notes/Photos

• Additional comments, evidence

• Add in any photos

  Media

• Add in any other notes