Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

SafetyCulture INCIDENT / INJURY REPORT FORM

  • 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:

  • Are you?

  • Sex:

  • Occupation:

  • Email Address:

  • Phone (W):

  • Phone (H):

  • Home address:
  • Date and time of incident:

  • Location:
  • How did the incident happen?

  • Signed:

  • Date:

  • Name/s of Witness/es:

  • 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.

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

  • Part/s of the body affected:

  • Date and time when symptoms noticed:

  • Was medical treatment given?

  • Name of person giving initial treatment:

  • Date and time initial treatment given:

  • Time lost due to injury?

  • 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?

  • Type of injury:

  • Safe Work Method Statements followed?

  • Identification of equipment/object/insect involved:

  • Equipment in good condition?

  • Date of last service of equipment:

  • Appropriate safety equipment (PPE) used?

  • Lighting adequate?

  • Housekeeping issues contributed?

  • Surface type:

  • Type of shoes worn:

  • Workload excessive?

  • Workload boring and repetitive?

  • If it was a slip or trip:

  • Height of fall / slip / trip?

  • Were you?

  • If stairs?

  • Did you fall on your?

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

  • If the incident involves manual handling:

  • Were work items within easy reach?

  • Ergonomic equipment available?

  • Was the equipment being used correctly?

  • Repetitive and/or forceful movements used?

  • Action involved:

  • 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:

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

  • By Whom:

  • By When:

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

  • By Whom:

  • By When:

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

  • By Whom:

  • By When:

  • Personal Protective Equipment (PPE) Action Required:

  • By Whom:

  • By When:

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

  • Signed:

  • Print Name:

  • Ph.:

  • Position:

  • Date:

  • Office Use Only (Health and Safety Recommendations)

  • OT

  • Date Part 2 received:

  • Date Completed:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.