Minni's INCIDIENT / INJURY REPORT FORM

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

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

• TO BE COMPLETED BY THE PERSON OR PERSONS DIRECTLY INVOLVED.

SECTION A: PERSONAL AND INCIDENT DETAILS

• TITLE

• LAST NAME

• OTHER NAME/S

• DATE OF BIRTH

  Date

• ARE YOU A?

  RELEVANT WORKER

  CONTRACTOR

  VISITOR

• SEX

  MALE

  FEMALE

• OCCUPATION

• EMAIL ADDRESS

• PHONE (W)

• PHONE (H)

• HOME ADDRESS
  Address

• DATE AND TIME OF INCIDENT

  Date

• LOCATION

• HOW DID THE INCIDENT HAPPEN?

• SIGNED

  Sign

• NAME/S OF WITNESS/ES

• DATE

  Date

• PHONE

Section B: SUPERVISOR or WORKSHOP MANAGER NOTIFICATION

• NAME OF WHS MANAGER

• DATE AND TIME OF INCIDENT

  Date

• SIGNED

  Sign

• DATE

  Date

• PHONE

• NAME OF SUPERVISOR

• DATE AND TIME OF INCIDENT

  Date

• SIGNED

  Sign

• DATE

  Date

• PHONE

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?<br>

  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

  No

  N/A

• How many hours / days?

• Incident / Injury: How do you think the incident / 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)?

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

• Any other comments or observations?

Please answer / select the most appropriate response/s:

• What sort of incident / injury occurred? Manual Handling / Occupational Overuse Syndromes (OOS) / cuts / bruises / burns / falls / slips / trips / vehicles / bicycles / hazardous substances / insects / animals / foreign body / plant / stress / other…

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

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

• What type of injury?

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

  • Sting
  • Bite
  • Kick
  • Puncture
  • Strain
  • Sprain
  • Hazardous Substance
  • 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?

• If stairs, are you going up or down?

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

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

If incident involves manual handling:

• 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

  • 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?

• 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 least effective methods, as shown below:
  
  This is the most important part of the investigation process! Do not leave blank.

RISK CONTROL Option : Elimination

• Do you have to do the task?

  Yes

  No

  N/A

• Action Required

• By Whom?

• By When?

RISK CONTROL Option : Substitution

• Is there another way you can do the task?

  Yes

  No

  N/A

• Action Required

• By Whom?

• By When?

RISK CONTROL Option : Engineering

• Can you engineer a way to make the job safer?

  Yes

  No

  N/A

• Action Required

• By Whom?

• By When?

RISK CONTROL Option : Administration

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

  Yes

  No

  N/A

• Action Required

• By Whom?

• By When?

Personal Protective Equipment (PPE)

• Action Required

• By Whom?

• By When?

NEXT

• Date feedback provided to person reporting the injury/incident

  Date

• SIGNED

  Sign

• Ph:

• Position

• DATE

  Date

Office Use Only

• (Health and Safety Recommendations)

• OT

• Date Part 2 received

  Date

• Date Completed:

  Date