SBC Injury Report - Rev B

• Completed on

  Date

• Completed by

• Document No.

Injured Person Details

• Full Name

• Age

• Occupation

• Contact Number

• Designation

  Site Worker

  Site Visitor

  General Public

  Strongbuild Employee

• Name of Employer

Injury Details

• Date and time the injury occurred

  Date

• What task was being performed at the time of the injury?

• How did the injury occur?

• What was the location on site where the injury occurred? ( Building / Level / Unit / Room )

Third party Property Damage

• Was there any third party property damage?

  Yes

  No

  N/A

• Provide a detailed description of the damage.

• Provide Photos

  Media

First Aid Treatment

• List the body part(s) injured.

  Select Head Forehead Cheek - Right Cheek - Left Chin Eye - Right Eye - Left Nose Ear - Right Ear - Left Lip - Upper Lip - Lower Neck Back - Upper Back - Lower Chest Ribs - Right Ribs - Left Abdomen Shoulder - Right Shoulder - Left Upper Arm - Right Upper Arm - Left Elbow - Right Elbow - Left Forearm - Right Forearm - Left Wrist - Right Wrist - Left Hand - Right Hand - Left Finger(s) - Right Finger(s) - Left Groin - Right Groin - Left Hip - Right Hip - Left Upper Leg - Right Upper Leg - Left Knee - Right Knee - Left Lower Leg - Right Lower Leg - Left Ankle - Right Ankle - Left Foot - Right Foot - Left Toe(s) - Right Toe(s) - Left

  • Head
  • Forehead
  • Cheek - Right
  • Cheek - Left
  • Chin
  • Eye - Right
  • Eye - Left
  • Nose
  • Ear - Right
  • Ear - Left
  • Lip - Upper
  • Lip - Lower
  • Neck
  • Back - Upper
  • Back - Lower
  • Chest
  • Ribs - Right
  • Ribs - Left
  • Abdomen
  • Shoulder - Right
  • Shoulder - Left
  • Upper Arm - Right
  • Upper Arm - Left
  • Elbow - Right
  • Elbow - Left
  • Forearm - Right
  • Forearm - Left
  • Wrist - Right
  • Wrist - Left
  • Hand - Right
  • Hand - Left
  • Finger(s) - Right
  • Finger(s) - Left
  • Groin - Right
  • Groin - Left
  • Hip - Right
  • Hip - Left
  • Upper Leg - Right
  • Upper Leg - Left
  • Knee - Right
  • Knee - Left
  • Lower Leg - Right
  • Lower Leg - Left
  • Ankle - Right
  • Ankle - Left
  • Foot - Right
  • Foot - Left
  • Toe(s) - Right
  • Toe(s) - Left

• List the type of injury(s) sustained?

  Select Laceration Crush Bruise Impact Fracture Broken Bone Severance Burn Puncture Concussion Respiratory Difficulty Foreign Body in Eye Contact with Energised Electricity Slip / Trip / Fall Heat Exhaustion Sprain / Strain Twist Insect Bite / Sting Dislocation Graze Chest Pain Other

  • Laceration
  • Crush
  • Bruise
  • Impact
  • Fracture
  • Broken Bone
  • Severance
  • Burn
  • Puncture
  • Concussion
  • Respiratory Difficulty
  • Foreign Body in Eye
  • Contact with Energised Electricity
  • Slip / Trip / Fall
  • Heat Exhaustion
  • Sprain / Strain
  • Twist
  • Insect Bite / Sting
  • Dislocation
  • Graze
  • Chest Pain
  • Other

• Provide details

• What First Aid was applied?

• By Whom?

• Did the injured person return to work after receiving First Aid treatment?

  Yes

  No

  N/A

Medical Treatment

• Did the injured person attend a medical facility for further medical attention?

  Yes

  No

  N/A

• Please provide as much information as possible in the following sections

Medical Facility Details

• What is the name of the medical facility attended?

• Was the person treated as an outpatient and release immediately after treatment?

  Yes

  No

  N/A

• Were there any witnesses to the actual event?

  Yes

  No

  N/A

• Witness Details

Witness

• Full Name

• Employer

• Occupation

• Contact Number

• Designation

  Site Worker

  Site Visitor

  General Public

  Strongbuild Employee

Notifiable Incident

• Reference - WHS Act Part 3
  https://www.legislation.nsw.gov.au/#/view/act/2011/10/part3

• Is the injury a notifiable incident?

  Yes

  No

  N/A

• Please contact our Systems Manager or HSEQ Advisor immediately. All Notifiable Incidents must be reported to SafeWork NSW.

• Is the Notifiable Incident a Serious Injury?

  Select No Immediate treatment as an in-patient in a hospital The amputation of any part of his or her body A serious head injury A serious eye injury A serious burn The separation of his or her skin from an underlying tissue (such as degloving or scalping) A spinal injury The loss of a bodily function Serious lacerations Medical treatment within 48 hours of exposure to a substance

  • No
  • Immediate treatment as an in-patient in a hospital
  • The amputation of any part of his or her body
  • A serious head injury
  • A serious eye injury
  • A serious burn
  • The separation of his or her skin from an underlying tissue (such as degloving or scalping)
  • A spinal injury
  • The loss of a bodily function
  • Serious lacerations
  • Medical treatment within 48 hours of exposure to a substance

• Is the Notifiable Incident a Dangerous Incident (Near Miss)

  Select No An uncontrolled escape, spillage or leakage of a substance An uncontrolled implosion, explosion or fire An uncontrolled escape of gas or steam An uncontrolled escape of a pressurised substance Electric shock The fall or release from a height of any plant, substance or thing The collapse, overturning, failure or malfunction of, or damage to, any plant that is required to be authorised for use in accordance with the regulations The collapse or partial collapse of a structure The collapse or failure of an excavation or of any shoring supporting an excavation The inrush of water, mud or gas in workings, in an underground excavation or tunnel The interruption of the main system of ventilation in an underground excavation or tunnel

  • No
  • An uncontrolled escape, spillage or leakage of a substance
  • An uncontrolled implosion, explosion or fire
  • An uncontrolled escape of gas or steam
  • An uncontrolled escape of a pressurised substance
  • Electric shock
  • The fall or release from a height of any plant, substance or thing
  • The collapse, overturning, failure or malfunction of, or damage to, any plant that is required to be authorised for use in accordance with the regulations
  • The collapse or partial collapse of a structure
  • The collapse or failure of an excavation or of any shoring supporting an excavation
  • The inrush of water, mud or gas in workings, in an underground excavation or tunnel
  • The interruption of the main system of ventilation in an underground excavation or tunnel

• Photos

  Media

SafeWork NSW Details

• Date and Time reported

  Date

• Reported by

• Name of SafeWork NSW representative you spoke to on the phone

• SafeWork NSW reference number

• Did SafeWork NSW release the site at the time of notification?

  Yes

  No

  N/A

• What instructions were given by SafeWork NSW?

Certificate of Capacity

• A worker who has attended a medical facility or doctor’s rooms for treatment must provide the initial WorkCover Certificate of Capacity as proof they are fit/unfit or have limited capacity for work.

• Example Certificate of Capacity

  

• Upload WorkCover Certificate of Capacity

  Media

• What actions did the injured person take?

• Add signature

  Sign