Near Miss and Incident Investigation - duplicate

• Conducted on

  Date

• Prepared by

• Location

  Blacktown

  Crossroads

  Auburn

PLEASE COMPLETE ALL FIELDS FULLY AND ACCURATELY

• Type of incident

  Select Work-related Injury Near Miss Machinery Machinery impact Impact to Racking Damage Physical Abuse or Threat Hazard Observation Fire Incident Enforcement Action Customer Related Incident Other N/A (You will be asked why)

  • Work-related Injury
  • Near Miss Machinery
  • Machinery impact
  • Impact to Racking
  • Damage
  • Physical Abuse or Threat
  • Hazard Observation
  • Fire Incident
  • Enforcement Action
  • Customer Related Incident
  • Other
  • N/A (You will be asked why)

• Is this incident likely to lead to an over 7 day absence?

  Yes

  No

• Time and Date of Incident

  Date

• Where did this occur?

  Blacktown

  Crossroads

  Auburn

1. Details of Affected Person

• Were there people injured/affected or involved in this Incident?

  Yes

  No

• Name

• Category of Person

  Employee (Permanent)

  Employee (Casual)

  Agency Worker

  Contractor

  Customer

• Involvement

  Select Machinery Operator Affected Person (No Injury) Injured Person Witness First on Scene Manager First Aider Security Other Involvement

  • Machinery Operator
  • Affected Person (No Injury)
  • Injured Person
  • Witness
  • First on Scene
  • Manager
  • First Aider
  • Security
  • Other Involvement

• If there was no injury involved in this Incident, please go direct to Section 5. About the Incident

2. Injury Assessment (If applicable)

• Severity Level

  Select Bruise, graze, scratch Amputation Anxiety/stress Asphyxia Back pain Bump/blow Burn/scald Broken bones(s)/fracture Dislocation (without fracture) Cut/laceration Puncture/penetration injury Foreign body Crush injury Chemical burn Electric shock/burn Effects of smoke Fatal Injury Hernia Loss of sight (temp or perm.) Sprain/strain Other injury No apparent injury Unknown N/A

  • Bruise, graze, scratch
  • Amputation
  • Anxiety/stress
  • Asphyxia
  • Back pain
  • Bump/blow
  • Burn/scald
  • Broken bones(s)/fracture
  • Dislocation (without fracture)
  • Cut/laceration
  • Puncture/penetration injury
  • Foreign body
  • Crush injury
  • Chemical burn
  • Electric shock/burn
  • Effects of smoke
  • Fatal Injury
  • Hernia
  • Loss of sight (temp or perm.)
  • Sprain/strain
  • Other injury
  • No apparent injury
  • Unknown
  • N/A

• Injury/Illness

  Select Bruise, graze, scratch Amputation Anxiety/stress Asphyxia Back pain Bump/blow Burn/scald Broken bones(s)/fracture Dislocation (without fracture) Cut/laceration Puncture/penetration injury Foreign body Crush injury Chemical burn Electric shock/burn Effects of smoke Fatal Injury Hernia Loss of sight (temp or perm.) Sprain/strain Other injury No apparent injury Unknown N/A

  • Bruise, graze, scratch
  • Amputation
  • Anxiety/stress
  • Asphyxia
  • Back pain
  • Bump/blow
  • Burn/scald
  • Broken bones(s)/fracture
  • Dislocation (without fracture)
  • Cut/laceration
  • Puncture/penetration injury
  • Foreign body
  • Crush injury
  • Chemical burn
  • Electric shock/burn
  • Effects of smoke
  • Fatal Injury
  • Hernia
  • Loss of sight (temp or perm.)
  • Sprain/strain
  • Other injury
  • No apparent injury
  • Unknown
  • N/A

• Part of Body

  Select Abdomen Ankle Arm Back/spine Chest Ear Elbow Eye Face Finger Foot Groin Hand Head Hip Internal Knee Leg Lung Mouth Neck Shoulder Toes Wrist N/A

  • Abdomen
  • Ankle
  • Arm
  • Back/spine
  • Chest
  • Ear
  • Elbow
  • Eye
  • Face
  • Finger
  • Foot
  • Groin
  • Hand
  • Head
  • Hip
  • Internal
  • Knee
  • Leg
  • Lung
  • Mouth
  • Neck
  • Shoulder
  • Toes
  • Wrist
  • N/A

• Area

  Select Upper Lower Inner Outer Cheek Chin Forehead Jaw Nose Thumb Index finger Middle digits Sole Big toe Little toe Back of hand Palm of hand Front Back Lips Inside mouth Teeth Unknown N/A

  • Upper
  • Lower
  • Inner
  • Outer
  • Cheek
  • Chin
  • Forehead
  • Jaw
  • Nose
  • Thumb
  • Index finger
  • Middle digits
  • Sole
  • Big toe
  • Little toe
  • Back of hand
  • Palm of hand
  • Front
  • Back
  • Lips
  • Inside mouth
  • Teeth
  • Unknown
  • N/A

• Side of Body

  Left

  Right

  N/A

• Injury Comments

3. Treatment Details (If Applicable)

• Was treatment given?

  Yes

  No

  N/A

• When was treatment given?

  Date

• Who provided the treatment?

  Select First Aider Doctor Bystanders Customer Dept Manager Other

  • First Aider
  • Doctor
  • Bystanders
  • Customer
  • Dept Manager
  • Other

• Nature of treatment:

4. After Initial Treatment

• What happened after the initial treatment?

  Select Return to work Resumed normal activities Sent or taken to hospital Referred to hospital Referred to dentist Referred to own GP Sent or taken home Other Not known

  • Return to work
  • Resumed normal activities
  • Sent or taken to hospital
  • Referred to hospital
  • Referred to dentist
  • Referred to own GP
  • Sent or taken home
  • Other
  • Not known

• Mode of transport (if leaving site)

  Yes

  No

  N/A

5. About the Incident

• Where did this occur

  Select Warehouse A (B) Warehouse B (B) Loading Dock (B) Customer Service In Store Warehouse (Cas) Loading Dock (Cas)

  • Warehouse A (B)
  • Warehouse B (B)
  • Loading Dock (B)
  • Customer Service
  • In Store
  • Warehouse (Cas)
  • Loading Dock (Cas)

• If OTHER, provide details

• Give as much detail as you can about: names of substances and equipment involved; circumstances leading up to the event, part played by all people involved and what the injured personas doing at the time of the incident.

• What were the sequence of events leading up to this incident taking place?

• What was the immediate cause of this incident?

• What equipment was being used at the time of the incident?

  Select Fork Lift Truck Order Picker Turret Single Section Ladder Double Section Ladder Platform Ladder Harness EWP

  • Fork Lift Truck
  • Order Picker
  • Turret
  • Single Section Ladder
  • Double Section Ladder
  • Platform Ladder
  • Harness
  • EWP

• What PPE was being used at the time?

  Select Harness Fall Arrestor Safety Boots Gloves Safety Goggles Dust Mask Safety Knife N/A

  • Harness
  • Fall Arrestor
  • Safety Boots
  • Gloves
  • Safety Goggles
  • Dust Mask
  • Safety Knife
  • N/A

• What Happened

• Add any relevant photos

  Media

• Add sketches (if needed)

  Drawing

• Were all of the correct procedures being carried out at the time?

  Yes

  No

• If NO, please describe why not.

• What was the Root Cause of this incident?

  Select Machinery failure Manual handling Operator Error Wire Guidance Failure Fall from height Slip,trip,fall same level Use of power tools Contact with electricity Struck by object Struck by moving vehicle Use of hand tools Other N/A

  • Machinery failure
  • Manual handling
  • Operator Error
  • Wire Guidance Failure
  • Fall from height
  • Slip,trip,fall same level
  • Use of power tools
  • Contact with electricity
  • Struck by object
  • Struck by moving vehicle
  • Use of hand tools
  • Other
  • N/A

• What time scale has been set to implement these actions?

• Are there any specific recommendations or action plans that you need to make in respect of this Near Miss or Incident? Please detail them here.

• Are extra resources required to assist the implementation of these actions?

  Yes

  No

• ...If YES, what are they and who have you contacted to arrange them?

• Have you fully implemented your Action Plan?

  Yes

  No

6. Agreement

• I agree that the information contained on this form is correct as far as I am aware.

• I understand that the company will use this information to meet its WH&S reporting and recording legal duties and for internal management purposes

• Investigator's Signature

  Sign