RPF Preliminary Incident and Investigation Report

• Please complete this form immediately after the emergency is under control. It MUST be submitted to the WHS Advisor within 24 hours of the incident occurring.

Part A - Incident Details – completed by Supervisor, immediately

1. REPORT DETAILS

• Job Number

• Address of Incident

• Date and Time of Incident

  Date

• Date and Time Incident Reported

  Date

• Reported by (Name and Position)

• Reporter Phone No

• Statutory Notification:

  Yes

  N/A

2. CLASSIFICATION – Refer to PRO-WHS-003 Incident Reporting and Investigation Procedure – Incident Classification Matrix

• Incident Type. NOTE: Incidents may have more than one category, please mark what proceeds

• Injury

  First Aid Injury

  Medical Treatment Injury

  Loss Time Injury

  Return to Work Injury

  Injury reported but not treated

• Occupational Illness

  Asbestos

  Mould

  Lead

  Other

• Property Damage

  Plant/Equipment/Property Damage

  Utility Damage

• Near Miss

  Injury or Illness

  Property Damage

• Procedural Breach

  Asbestos

  Mould

  Lead

  Other

• Report Only

  Journey event

  Other

• Security (including public trespass, theft or damage) Other:

  Trespass

  Theft

  Damage

  Other

3. THE INCIDENT

• What task was being done? (As per SWMS describe the activity that was being undertaken at the time.)

• What happened? (Detailed description of when, where, how and why the event/accident/loss occurred.)

• Details of any Immediate Actions taken in response to the event

4. PEOPLE INVOLVED - Have people write up witness statements

• Name

• Involvement

  Select Injured Witness Victim Driver/Operator Person at Fault Other

  • Injured
  • Witness
  • Victim
  • Driver/Operator
  • Person at Fault
  • Other

• Company

• Position/Job

• Phone Number

5. INJURY DETAILS

• If not a personal injury tick N/A

  Yes

  N/A

• Treatment Level

  Nil

  Site

  Doctor

  First Aid

• Type of Injury

  Select Bruising Sprain/Strain Laceration Pain Fracture Swelling Other

  • Bruising
  • Sprain/Strain
  • Laceration
  • Pain
  • Fracture
  • Swelling
  • Other

• Body Location

  Left

  Right

• Take Photo of Injury

  Media

• First Aid Given applied on site:

  Yes

  N/A

• Treatment Given & Equipment Used:

• Pre-existing Condition:

  Yes

  N/A

• First Aider Name and Phone Number:

• Has First Aider completed a First Aid Record Form

  Yes

  N/A

6. PLANT/EQUIPMENT/INFRASTRUCTURE INVOLVED

• If not a Plant/Equipment/Infrastructure Damage Incident tick NA

  Yes

  N/A

• Plant ID/License Plate No

• Damage

  Yes

  N/A

• Expected Damage Cost (AUD$)

• Operator/ Driver’s Name

• Company (Employer, Member of Public, Visitor)

• Police Report No

• Take Photo of Damage and incident scene

  Media

7. ATTENDANCE TO SITE

• Did any third party attend the site? e.g. emergency services, relevant authority, media - If not attendance tick NA

  Select Ambulance Police Fire Brigade Relevant Authority Media N/A

  • Ambulance
  • Police
  • Fire Brigade
  • Relevant Authority
  • Media
  • N/A

• Did a Safety Authority attend the site?

  Yes

  N/A

• Name of Authority

• Authority’s Rep. Name & Position

9. SIGNATURES OF PERSONS COMPLETING PART A:

• Signature

  Sign

Part B – Preliminary Investigation - conducted by Supervisor or Manager

• CONTRIBUTING FACTORS – Give details of the factors that led to the incident, what is the cause?

• ACTIONS TO PREVENT RECURRENCE - Each Contributing Factor must be addressed in the Actions to prevent recurrence

• Who is responsible to ensure action is taken?

• By what date should the action been taken?

  Date

• Is further investigation required?

  Yes

  N/A

13. SIGNATURE OF PERSON COMPLETING PART B:

• Signature

  Sign