Safety Culture Incident/Injury Report Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Information details

• The person reporting is to follow the Incident and Accident Policy. Then complete this report and provide it to the
  workshop manager within one hour or as soon as practical.

• Name:

• Are you?

  Worker

  Contractor

  Visitor

  N/A

• Date of Birth:

  Date

• Sex:

• Occupation:

• Email address:

• Phone number:

• Date and Time of Incident/Injury:

  Date
• Location of Incident:
  Address

• How did the Incident/Injury happen?

• Injured party signature

  Sign

• Date signed:

  Date

Supervisor/Workshop Manager Notification

• WHS Manager:

• Date and Time of Incident:

  Date

• Phone number:

• WHS Manager Signature

  Sign

• Date signed:

  Date

• Supervisor:

• Date and Time of Incident:

  Date

• Phone number:

• Supervisor Signature

  Sign

• Date signed:

  Date

Injury Details

• Body part/s affected:

• Date and Time when symptoms noticed:

  Date

• Was medical attention given?

  Yes

  No

  N/A

• Please specify Medical Practitioner's name:

• Date and Time Initial Treatment was given:

  Date

• Time lost due to injury?

  Yes

  No

• How many hours and days?

Investigation checklist

• Incident / Injury: How do you think the incident / injury happened and what were you doing at the time?

• How long has the worker been working prior to the incident/injury?

• How long had you been working on this task?

• Is the task part of the worker's normal duties?

  Yes

  No

• What is the worker doing during the time of Incident/Injury?

• Have you been instructed / trained in this task?

  Yes

  No

• What were you doing in the time prior to the incident / injury?

• Are there any other factors involved (e.g. management, the work environment, equipment, maintenance, individual) ?

  Yes

  No

  N/A

• Please specify:

• Is the nature of Incident/Injury related to the worker's task?

  Related

  Not related

• Cuts

• Manual handling

• Burns

• Bruises

• Falls /Slips / Trips

• Vehicles / Bicycles

• Hazardous substances

• Insects / Animals

• Foreign Body

• Plant

• Stress/Psychological factor

• Safe Work Method Statements followed?

  Yes

  No

  N/A

Identification of Equipment/Factors involved

• Equipment in good condition?

  Yes

  No

  N/A

• Date of last service of equipment?

  Date

• Appropriate safety equipment (PPE) used?

  Yes

  No

  N/A

• Lighting adequate?

  Yes

  No

  N/A

• Housekeeping issues contributed?

  Yes

  No

  N/A

• Surface type?

  Dry Surface

  Wet Surface

  Other type of surface

  N/A

• Please specify:

• Type of shoes worn?

  Open shoes

  Closed Shoes

  Other type of footwear

  N/A

• Please specify:

• Is Workload excessive?

  Yes

  No

  N/A

• Is the Task boring and repetitive?

  Yes

  No

  N/A

• Is the Incident/Injury related to a fall/slip/trip?

  Yes

  No

  N/A

• Height of fall / slip / trip?

• Did you fall on your front / back / side?

• Was the worker in motion during the fall/slip/trip?

  Yes

  No

  N/A

• Walking

• Running

• Jumping

• Other

• Please specify:

• Is the worker on the stairs?

  Yes

  No

  N/A

• Worker is going up

• Worker is going down

• Worker carrying/lifting an item/object?

  Yes

  No

• Please specify:

• Does Incident/Injury involves Manual Handling?

  Yes

  No

• Were work items within easy reach?

  Yes

  No

  N/A

• Ergonomic equipment available?

  Yes

  No

  N/A

• Was the equipment being used correctly?

  Yes

  No

  N/A

• Repetitive and/or forceful movements involved?

  Yes

  No

• Reaching/Catching

• Lifting/Carrying

• Stooping/Sitting/Lowering

• Pushing/Pulling

• Weight of Object?

• Distance carried / position of object moved from / to?

• Height of load?

To be completed by WHS Manager

• Investigator’s comments and observations:

• Elimination - Do you have to do the task?

  Yes

  No

  N/A

• By Whom and When?

• Substitution – is there another way<br>you can do the task?

  Yes

  No

  N/A

• How and When?

• Administration – can you improve<br>work practices? E.g. limit time of<br>exposure.

  Yes

  No

  N/A

• How and When?

• Personal Protective Equipment (PPE)?

  Yes

  No

  N/A

• Please specify:

• Date feedback provided to person reporting the injury/incident:

  Date

• Signed:

  Sign

• Position:

• Phone number:

• Date signed:

  Date

• Office Use Only (Health and Safety Recommendations)
  

• Date Part 2 received:

  Date

• Date Completed:

  Date