Information
-
Conducted on
-
Prepared by
1. DETAILS OF INCIDENT
-
Name of worker
-
Worker's job title
-
Place where incident occurred
-
Date and time of incident
-
To whom was the incident reported?
-
Was there any witness(es)? If yes, provide name(s).
-
Witness statement
2. INCIDENT TYPE
-
Select category
- Near Miss/Non Injury
- First Aid Injury
- Medical Treatment
- Lost Time Injury
- Vehicle
- Property
- Hazardous Substance
- Medical Gas
- Fatality
- Other - give details
3. DETAILS OF INJURY, IF APPLICABLE
-
Injury type
- Strain/sprain
- Fracture
- Bruising
- Laceration - deep cut or tear to skin
- Dislocation
- Chemical Reaction
- Burn/Scald
- Slip, trip, fall
- Sharp Object
- N/A
- Other - Describe below
-
Part of body injured
- Face
- Head
- Eye
- Chest
- Back
- Neck
- Hand
- Finger
- Arm
- Leg
- Foot
- Other; explain
-
Take photo
-
Other Information
4. VEHICLE/PROPERTY DAMAGE
-
Choose category
- N/a
- Vehicle
- Property - on site
- Private Property
- Other, please add comment below
-
Describe incident
-
Vehicle ID No.
-
Take photo
-
Other Comments
5. ANALYSIS - Describe incident
-
Select Category
- Machinery or (mainly) fixed plant
- Mobile Plant or Transport
- Power Equipment, Tool or Appliance
- Non-powered Hand Tool, Appliance or Equipment
- Chemical or Chemical Product
- Material or Substance
- Environmental Exposure (e.g. dust, gas)
- Animal, Human or Biological Agency
- Bacteria or Virus
- Sharps e.g. needlestick, glass
- Property
- Medical Gas
- Other - describe below
- N/A
-
What Happened?
-
What could have potentially happened?
-
State what PPE was worn
-
Corrective Action (Include detail description of action and person(s) responsible for actions)
-
Preventative Measures (How to stop the incident/accident happening again)
-
Hierarchy of controls applied
- 1. Eliminate hazard - remove completely from your site
- 2. Substitute the hazard - with a safer alternative
- 3. Isolate the hazard - as much as possible away from the workers
- 4. Use engineering controls - adapt tools or equipment to reduce the risk
- 5. Use administrative controls - change work practices and organisation
- 6. Use personal protective equipment (PPE)
- 7. Combination of the above, list numbers
- N/A
-
Other comments
6. OTHER COMMENTS: SUBMIT PHOTOS
-
Other information/documentation/photos
-
Add media
-
REMINDER: TO DISCUSS AT YOUR NEXT TOOLBOX
7. SIGNATURES REQUIRED
-
Signature of Worker
-
Signature of Witness
-
Signature of Manager/Supervisor: (Verifies the above information is correct to the best of their knowledge)
-
PLEASE SAVE A COPY INTO YOUR E-FOLDER
