Safety Culture Technical Assessment

Title Page

INCIDENT / INJURY REPORT FORM

TO BE COMPLETED BY THE PERSON OR PERSONS DIRECTLY INVOLVED.

PART 1: INSTRUCTIONS

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.
Section A: Personal and Incident Details (Complete Responses)
Title:
Last Name:
Other Name/s:
Date of Birth:
Are you? Relevant Worker Contractor Visitor
Sex:
Male
Female
Occupation:
Email Address:
Phone (H)
Phone (W)
Home Address:
Date and Time of Incident:
How did the incident happen?
Signed:
Name/s of Witness/es:
Date:
Phone:

SECTION B: SUPERVISOR OR WORKSHOP MANAGER NOTIFICATION

Name of WHS Manager:
Date and Time of Incident:
Signed:
Date:
Phone:
Name of Supervisor:
Date and Time of Incident:
Signed:
Date:
Phone:
SECTION C: INJURY DETAILS (If applicable) Use this section to also report workplace disease.

continuation of SECTION C:

continuation of SECTION C:

Part 2: INVESTIGATION CHECKLIST AND ACTION REPORT FORM

Incident / Injury: How do you think the incident happened and what were you doing at the time?
Investigation Checklist:
How long had you been working prior to the incident / injury?
How long had you been working in this task?
Is this task part of your normal duties?
Have you been instructed /t rained in this task?
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)?
What do you think could have been done to prevent this incident from occurring?
Any other comments or observations?

continuation of SECTION C:

Please answer the following:
What sort of incident / injury occurred? Manual Handling / Occupational Overuse Syndrome (OSS) / cuts/ bruises / burns / falls / slips / trips / vehicles / bicycles / hazardous substances / insects / animals / foreign body / plant / stress / other
Type of injury: Sting / bite / kick / puncture / strain / sprain / hazardous substance / slip / trip / fall / other
Safe Work Method followed?
Yes
No
N/A

Identification of equipment/object/insect involved:

Equipment in good condition? Yes / No / NA
Date of last service of equipment:
Appropriate safety equipment (PPE) used? Yes / No / NA
Lightning adequate? Yes / No / NA
Housekeeping issues contributed? Yes / No / NA
Surface type: Cement / tiles / grass / dry / wet / damaged / torn / sand / footpath / carpet / gravel / rocks / road / other
Type of shoes worn: Open / closed / boots / high heels / sandals / none / other
Workload excessive? Yes / No / NA
Workload boring and repetitive? Yes / No / NA

continuation of: Identification of Equipment/Object/Insect Involved:

It was a slip or trip?
Height of fall / slip / trip?
Were you running / walking / turning a corner / jumping / other?
If stairs - going up or going down?
What were you carrying (if anything) at the time?
If the incident involves manual handling:
Were work items within easy reach? Yes / No / NA
Ergonomic equipment available? Yes / No / NA
Was the equipment being used correctly? Yes / No / NA
Repetitive and/or forceful movements used? Yes / No / NA
Action involved: Reaching / bending / stooping / sitting / kneeling / twisting / pushing / pulling / lifting / catching / lowering / carrying
Weight of object?
Distance carried / position of object moved from / to?
Height of load?

PART 3: TO BE COMPLETED BY WHS MANAGER

Investigator's comments and observations from Part 2:
RECOMMENDATIONS: A hierarchy of control should be used to assist with the prevention of future similar injuries. The 'hierarchy of control' depicts the most to the least effective methods, as shown in the table below.

This us the most important part of the investigation process! Do not leave blank.
Add media
Office use only (Health and Safety Recommendations)
OT
Date Part 2 received:
Date completed: