QVM Injury & Incident Report

• Document No.

• Conducted on

  Date

• Prepared by

• INSTRUCTIONS:
  Part A, B and C to be completed for all Incidents
  Part D to be completed if the incident has resulted
  in an injury
  Part E to be completed by First Aid Responder
  Part F to be completed only if damage has
  occurred to equipment or property
  Part G, H and I to be completed for all incidents

Report: Part A - Personnel Details

• Name of person involved in incident:

• Phone Number:

• Date of Birth:

  Date

• Gender:

  Male

  Female

• Name of Witness:

• Role of person involved in incident:

  Shopper/Visitor

  Employee

  Trader

  Contractor

  Other

• Name of Supervisor/Manager:

• Street:

• City:

• State:

  Select VIC NSW QLD TAS WA SA

  • VIC
  • NSW
  • QLD
  • TAS
  • WA
  • SA

• Postcode:

Report: Part B - The Incident

• Location of Incident:

  Stall

  Common space

  Office

  Other

• Shed and stall number:

• Describe location:

• Photo of location:

  Media

• Date & Time of Incident:

  Date

• Date & Time Incident was Reported:

  Date

• Details of Incident:

• Describe what actually occurred. Include all relevant background information including the sequence of events leading up to the incident.

Report: Part C - Conditions

• Ground/floor surface:

  Concrete

  Asphalt

  Tiles

  Bluestone

  Other

• Describe surface:

• Surface condition:

  Clean

  Wet

  Dirty

  Uneven

  Other

• Describe condition:

• Weather:

  Clear

  Rain

  Windy

  Hot

  Other

• Describe weather:

• Lighting:

  Good

  Dim

  Artificial

  Bright

  Other

• Describe lighting:

• Did the incident result in an injury?

  Yes

  No

• Type of Footwear worn by injured person:

  Select Street shoes Safety boots Trainers / runners High heeled Womens flats Fashion boots Thongs / flip flops Sandals Other

  • Street shoes
  • Safety boots
  • Trainers / runners
  • High heeled
  • Womens flats
  • Fashion boots
  • Thongs / flip flops
  • Sandals
  • Other

• Go to Report: Part D & E - Injury and First Aid (next section)

• Go to Report: Part F - Equipment & Property Damage

Report: Part D - Injury / Illness details

• Type of Injury (select all that apply)

  Select Cut Heat burn Chemical burn Electrocution Sprain/strain Bruising Fracture Crushing Abrasion / graze Foreign body Hearing loss Breathing / Asthma Bleeding Pain Swelling Skin disorder / dermatitis Infectious disease Other

  • Cut
  • Heat burn
  • Chemical burn
  • Electrocution
  • Sprain/strain
  • Bruising
  • Fracture
  • Crushing
  • Abrasion / graze
  • Foreign body
  • Hearing loss
  • Breathing / Asthma
  • Bleeding
  • Pain
  • Swelling
  • Skin disorder / dermatitis
  • Infectious disease
  • Other

• Part of body affected: (eg head, left knee, right index finger)

Report: Part E - First Aid Treatment

• Was treatment offered to the injured person?

  Yes

  No

• Was treatment accepted by the injured person?

  Yes

  No

• Describe First Aid treatment provided:

• Is there a history of this illness / injury?

  Yes

  No

• Outline history of illness / injury:

• Is the ill / injured person taking any Medication?

  Yes

  No

• Provide details of Medications being taken:

• Does the ill / injured person have any known allergies?

  Yes

  No

• Provide details of known allergies:

• Patient Observations:

Time

• Time:

  Date

• Consciousness:

  Fully conscious

  Drowsy

  Unconscious

• Pupils:

  Normal

  Dilated

• Pulse rate:

  Normal

  Slow

  Fast

  Racing

  Not assessed

• Breathing:

  Normal

  Slow

  Fast

  Racing

  Not assessed

• Skin condition: (select all that apply)

  Select Normal Hot Cool Cold Dry Moist Wet

  • Normal
  • Hot
  • Cool
  • Cold
  • Dry
  • Moist
  • Wet

• Other Observations:

• Assessment:

• Follow up / Referral:

  None

  Doctor

  Ambulance

  Hospital

  Other

• Outline follow up / referral:

• Next of Kin notified?

  Yes

  No

• Name of Next of Kin:

• Name & signature of First Aid provider:

  Sign

• Go to Report: Part F - Equipment & Property Damage

Equipment / Property Damage

• Has the incident resulted in any damage to equipment or property?

  Yes

  No

• Add items by tapping on blue Plus + sign

• Equipment / Property Damage:

Item

• Item damaged:

• Item owner:

  QVM

  Employee

  Contractor

  Trader

  Shopper / Public

• Description of damage:

• Photo of damaged item:

  Media

• Go to Investigation: Part G - Causation

PEOPLE: What People issues were involved in the incident?

• Examples of People issues include:
  • Competency
  • Supervision
  • Procedures
  • Training

• Description of People issues:

• Root Cause of People issues:

EQUIPMENT: What plant/equipment/material issues were involved in the incident?

• Examples of Equipment issues include:
  • Operating correctly
  • Maintenance
  • Guarding
  • Signage
  • Training
  • Procedures

• Description of Equipment issues:

• Root Cause of Equipment issues:

ENVIRONMENT: What issues to do with the work environment/natural environment were involved in the incident?

• Examples of Environment issues include:
  • Lighting
  • Noise
  • Work space
  • Surfaces
  • Storage area

• Description of Environment issues:

• Root Cause of Environment issues:

PROCEDURES: What procedural or systems issues were involved in the incident?

• Examples of Procedure issues include:
  • Lack of procedure
  • Not current
  • Incorrect

• Description of Procedure issues:

• Root Cause of Procedure issues:

• Add new Corrective Actions by tapping on blue Plus + sign

• Corrective Actions to Prevent Recurrence

Action

• Description of Action:

• By Whom (Name):

• By When (Date):

  Date

• Type name then tap green pen icon to enter signature using touch screen.

• OHS Rep / OHS Committee Member: (Name & Sign)

  Sign

• Comments:

• Direct Manager: (Name & Sign)

  Sign

• Comments:

• Compliance Officer: (Name & Sign)

  Sign

• Comments: