NIKKIS OSHBOX Incident Record 2021

• Type of Incident

  Incident (Near Miss)

  Injury

  Illness

  Environmental

  Notifiable Event

• Conducted on

  Date

• Name of person filling in form

• Reported by:

  Select Officer Employee Contractor Visitor

  • Officer
  • Employee
  • Contractor
  • Visitor

• Their name/s:

• Their email address/es:

• Their phone number:

• The workflow

• Date:

  Date

• Location:

• Name of Injured person:

• Officer

  Employee

  Contractor

  Visitor

• Address of injured person:

• Occupation of injured person:

• Age of injured person:

• Phone of injured person:

• Email address of injured person:

• Length of Employment (if a staff member):

• Was a drug test performed

  Yes

  No

• What was the result:

• Particulars of Incident (Describe what happened, add photos or take a picture of a drawn diagram)

• Nature of Injury (What part of the body is affected and how, take pictures if applicable and permission given):

• Property Damage (What damage was caused and how):

• Analysis (What do you think caused or contributed to the incident)?

• Prevention (What action has been taken to prevent a reoccurrence)?

• Have all preventative actions been reviewed by management and implemented?

  Yes

  No

• Name of first Aider:

• Manager Sign:

  Sign

• Worker Sign:

  Sign

Witness/s

• Name:

• Phone:

Treatment:

• Medical Centre/A&E/Hospital:

• Doctor:

• Type of treatment provided:

Notification and Investigation (WORKSAFE PHONE: 0800 030 040 (24 hours) In the event of a Notifiable Event, an Incident Investigation must be completed and submitted to WorkSafe

• WorkSafe advised by:

• Date/Time:

  Date

• Investigation conducted by:

• Date/Time:

  Date

• Hazard/Risk Register updated by:

• Date/Time:

  Date

• Toolbox Meeting held for:

• Date/Time:

  Date