SAFETYCULTURE INCIDENT / INJURY REPORT FORM

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

SafetyCulture INCIDENT / INJURY REPORT FORM

• Date:

  Date

• 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 (CIRCLE OR COMPLETE RESPONSES)

• Title:

• Last Name:

• Other Name/s:

• Date of Birth:

  Date

• Are you?

  Relevant Worker

  Contractor

  Visitor

• Sex:

  Male

  Female

• Occupation:

• Email Address:

• Phone (W):

• Phone (H):

• Home address:
  Address

• Date and time of incident:

  Date
• Location:
  Address

• How did the incident happen?

• Signed:

  Sign

• Date:

  Date

• Name/s of Witness/es:

• Phone:

• Section B: SUPERVISOR or WORKSHOP MANAGER NOTIFICATION

• Name of WHS Manager:

• Date and time of incident:

  Date

• Signed:

  Sign

• Date:

  Date

• Phone:

• Name of Supervisor:

• Date and time of incident:

  Date

• Signed:

  Sign

• Date:

  Date

• Phone:

• Section C: INJURY DETAILS (If applicable) Use this section to also report workplace disease.

• Type of injury or disease (e.g. burn)

• Part/s of the body affected:

• Date and time when symptoms noticed:

  Date

• Was medical treatment given?

  No

  First Aid

  Nurse

  Doctor

  Hospital

• Name of person giving initial treatment:

• Date and time initial treatment given:

  Date

• Time lost due to injury?

  Yes

  No

  N/A

• How many hours / days?

PART 2: INVESTIGATION CHECKLIST AND ACTION REPORT FORM

• Incident / Injury: How do you think the incident / injury 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 on this task?

• Is this task part of your normal duties?

• Have you been instructed / trained 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?

• Please answer the most appropriate response/s:

• What sort of incident / injury occurred?

  Select Manual Handling Occupational Overuse Syndromes (OOS) cuts bruises burns falls slips trips vehicles bicycles hazardous substances insects animals foreign body plant stress other…

  • Manual Handling
  • Occupational Overuse Syndromes (OOS)
  • cuts
  • bruises
  • burns
  • falls
  • slips
  • trips
  • vehicles
  • bicycles
  • hazardous substances
  • insects
  • animals
  • foreign body
  • plant
  • stress
  • other…

• Type of injury:

  Select Sting bite kick puncture strain sprain hazardous substance slip trip fall other…

  • Sting
  • bite
  • kick
  • puncture
  • strain
  • sprain
  • hazardous substance
  • slip
  • trip
  • fall
  • other…

• Safe Work Method Statements followed?

  Yes

  No

  N/A

• Identification of equipment/object/insect 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:

  Select Cement tile grass dry wet damaged torn sand footpath carpet gravel rocks road other…

  • Cement
  • tile
  • grass
  • dry
  • wet
  • damaged
  • torn
  • sand
  • footpath
  • carpet
  • gravel
  • rocks
  • road
  • other…

• Type of shoes worn:

  Select Open closed boots high heels sandals none other…

  • Open
  • closed
  • boots
  • high heels
  • sandals
  • none
  • other…

• Workload excessive?

  Yes

  No

  N/A

• Workload boring and repetitive?

  Yes

  No

  N/A

• If it was a slip or trip:

• Height of fall / slip / trip?

• Were you?

  running

  walking

  turning a corner

  jumping

  other

• If stairs?

  going up

  going down

• Did you fall on your?

  front

  back

  side

• What were you carrying (if anything) at the time?

• If the incident involves manual handling:

• 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 used?

  Yes

  No

  N/A

• Action involved:

  Select Reaching bending stooping sitting kneeling twisting pushing pulling lifting catching lowering carrying

  • 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 is the most important part of the investigation process! Do not leave blank.

• Risk Control Options

• Elimination – do you have to do the task? Action Required:

• By Whom:

• By When:

  Date

• Substitution – is there another way you can do the task? Action Required:

• By Whom:

• By When:

  Date

• Engineering – can you engineer a way to make the job safer? Action Required:

• By Whom:

• By When:

  Date

• Administration – can you improve work practices? E.g. limit time of exposure. Action Required:

• By Whom:

• By When:

  Date

• Personal Protective Equipment (PPE) Action Required:

• By Whom:

• By When:

  Date

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

  Date

• Signed:

  Sign

• Print Name:

• Ph.:

• Position:

• Date:

  Date

• Office Use Only (Health and Safety Recommendations)

• OT

• Date Part 2 received:

  Date

• Date Completed:

  Date