SPC Accident Report Form 401

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• DATE REPORTED TO MANAGEMENT

  Date

• REPORTED BY:

DETAILS OF PERSON INJURED:

• FULL NAME:

• ADDRESS

• TELEPHONE NUMBER:

• DATE OF BIRTH:

• GENDER:

  MALE

  FEMALE

• BASIS OF EMPLOYMENT OR OTHER STATUS:

  Select FULL TIME PART TIME CASUAL TRAINEE WORK EXPERIENCE CONTRACTOR SELF-EMPLOYED FAMILY MEMBER VISITOR CLIENT CUSTOMER

  • FULL TIME
  • PART TIME
  • CASUAL
  • TRAINEE
  • WORK EXPERIENCE
  • CONTRACTOR
  • SELF-EMPLOYED
  • FAMILY MEMBER
  • VISITOR
  • CLIENT CUSTOMER

ACCIDENT DETAILS:

• ACCIDENT RESULTS:

  Select First Aid Only Property Damage Private Transportation Medical Treatment Hazard Report Ambulance Hospitalized Near Miss Flying Doctor SES Helicopter

  • First Aid Only
  • Property Damage
  • Private Transportation
  • Medical Treatment
  • Hazard Report
  • Ambulance
  • Hospitalized
  • Near Miss
  • Flying Doctor
  • SES Helicopter

• EXTENT AND NATURE OF PERSONAL INJURY:

• DETAILS OF IMMEDIATE TREATMENT GIVEN:

• WILL ANY FURTHER TREATMENT BE NECESSARY?

• IF VEHICLE INVOLVED, PROVIDE ALL DETAILS:

CAUSATIVE AGENTS AND INJURY REGISTER

• IN WHAT AREAS OF THE WORKPLACE/PROPERTY DID THE INJURY OCCUR?

  Select Pen / Paddock Workshop Channel / Dam / River Grain Storage Area Chemical Storage Machinery-shed Airstrip / LZ Silos Road (Public) Road (Private) Feed Mill Other

  • Pen / Paddock
  • Workshop
  • Channel / Dam / River
  • Grain Storage Area
  • Chemical Storage
  • Machinery-shed
  • Airstrip / LZ
  • Silos
  • Road (Public)
  • Road (Private)
  • Feed Mill
  • Other

• WHAT WERE THE CAUSATIVE AGENTS OF HTE INJURY?

  Select Tractor Falls from heights Slips, Trips, Falls Crane Tools Vehicle Frontend Loader Slasher / Mulcher Hazardous Substances Grain Auger Machinery Entanglement Working at Heights Cool-Room Field Bin Seeder / Planter Chaser Bin Cultivator Module Builder Manual Handling Silo Horse Livestock Elevator System Electricity Trenching Mixing Facility Ag-Bike ATV ( 4 Wheel Bike) Confined Space Gates / Fences Spray Unit Chainsaw Pumps Water (drowning) Fuel Explosives Weapons Protruding Object Other

  • Tractor
  • Falls from heights
  • Slips, Trips, Falls
  • Crane
  • Tools
  • Vehicle
  • Frontend Loader
  • Slasher / Mulcher
  • Hazardous Substances
  • Grain Auger
  • Machinery Entanglement
  • Working at Heights
  • Cool-Room
  • Field Bin
  • Seeder / Planter
  • Chaser Bin
  • Cultivator
  • Module Builder
  • Manual Handling
  • Silo
  • Horse
  • Livestock
  • Elevator System
  • Electricity
  • Trenching
  • Mixing Facility
  • Ag-Bike
  • ATV ( 4 Wheel Bike)
  • Confined Space
  • Gates / Fences
  • Spray Unit
  • Chainsaw
  • Pumps
  • Water (drowning)
  • Fuel
  • Explosives
  • Weapons
  • Protruding Object
  • Other

• PLEASE SPECIFY:

WHICH BODY PART WAS INJURED:

• HEAD

• What was the type of injury? (E.g. Fracture, cuts, etc)

• EYES

• What was the type of injury? (E.g. Fracture, cuts, etc)

• NECK

• What was the type of injury? (E.g. Fracture, cuts, etc)

• SHOULDER

• What was the type of injury? (E.g. Fracture, cuts, etc)

• CHEST

• What was the type of injury? (E.g. Fracture, cuts, etc)

• UPPER ARM

• What was the type of injury? (E.g. Fracture, cuts, etc)

• LOWER ARM

• What was the type of injury? (E.g. Fracture, cuts, etc)

• HAND

• What was the type of injury? (E.g. Fracture, cuts, etc)

• FINGER

• What was the type of injury? (E.g. Fracture, cuts, etc)

• RIBS

• What was the type of injury? (E.g. Fracture, cuts, etc)

• STOMACH / ABDOMEN

• What was the type of injury? (E.g. Fracture, cuts, etc)

• BACK

• What was the type of injury? (E.g. Fracture, cuts, etc)

• GROIN

• What was the type of injury? (E.g. Fracture, cuts, etc)

• THIGH

• What was the type of injury? (E.g. Fracture, cuts, etc)

• HAMSTRING

• What was the type of injury? (E.g. Fracture, cuts, etc)

• KNEES

• What was the type of injury? (E.g. Fracture, cuts, etc)

• LOWER LEG

• What was the type of injury? (E.g. Fracture, cuts, etc)

• ANKLE

• What was the type of injury? (E.g. Fracture, cuts, etc)

• FOOT

• What was the type of injury? (E.g. Fracture, cuts, etc)

• TOE(S)

• What was the type of injury? (E.g. Fracture, cuts, etc)

• OTHER

• PLEASE SPECIFY

• What was the type of injury? (E.g. Fracture, cuts, etc)