TECSIDE Accident / Incident / Hazard Report & Investigation Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Accident, Incident, Hazard Report Only

• Injury Report

Accident / Incident / Hazard Details

• Employee Name & Occupation:

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• To whom was the incident reported?

• Location of incident and task being performed:

• Was there any witness(es)? If yes, provide name(s).

  Yes

  No

  N/A

• Length of time injured person in position:

• Level of training of injured person:

• Outcome:

  Select Injury Property damage Product damage No damage Report only

  • Injury
  • Property damage
  • Product damage
  • No damage
  • Report only

Accident / Incident Description

• Classification of Injury / Incident:

  Select Near Miss Medical Treatment (MTI) Lost Time Injury (LTI) First Aid Only (FAI) Equipment Damage Chemical Spill Minor Injury Hazard Report Other

  • Near Miss
  • Medical Treatment (MTI)
  • Lost Time Injury (LTI)
  • First Aid Only (FAI)
  • Equipment Damage
  • Chemical Spill
  • Minor Injury
  • Hazard Report
  • Other

• Cause of injury / Incident:

  Select Fall, Trip, or Slip Chemical & Other Substances (gases etc) Heat Radiation & Electricity Push, Pull & Lift Hitting body against objects Objects hitting body Stepping on Mental Stress Sound & Pressure Disease Hazard Report only Hand or Power Tool Fire / Explosion Inhalation / Ingestion Animal or Insect Vehicle Falling / Flying object other

  • Fall, Trip, or Slip
  • Chemical & Other Substances (gases etc)
  • Heat
  • Radiation & Electricity
  • Push, Pull & Lift
  • Hitting body against objects
  • Objects hitting body
  • Stepping on
  • Mental Stress
  • Sound & Pressure
  • Disease
  • Hazard Report only
  • Hand or Power Tool
  • Fire / Explosion
  • Inhalation / Ingestion
  • Animal or Insect
  • Vehicle
  • Falling / Flying object
  • other

• Injured Body Part:

  Select Head Face Eye Shoulder Upper arm Fore arm leg / thigh Knee Foot / Ankle Toes Neck Upper Back Lower Back Hand / Wrist Multiple Other

  • Head
  • Face
  • Eye
  • Shoulder
  • Upper arm
  • Fore arm
  • leg / thigh
  • Knee
  • Foot / Ankle
  • Toes
  • Neck
  • Upper Back
  • Lower Back
  • Hand / Wrist
  • Multiple
  • Other

• Nature of Injury:

  Select Cut Burn Foreign bodies Abrasion / Laceration Dislocation Amputation Sprain / Strain Bruising Poisoning/bite/sting Break Dermatitis Other

  • Cut
  • Burn
  • Foreign bodies
  • Abrasion / Laceration
  • Dislocation
  • Amputation
  • Sprain / Strain
  • Bruising
  • Poisoning/bite/sting
  • Break
  • Dermatitis
  • Other

• Description of injury:

• Image of incident / accident if appropriate

  Media

• A detailed statement of accident/incident by injured worker or person/s involved in the accident/ incident. (What happened? - Who, what, when and where?)

• Please below type name, sign and date the above statement as a true account of what occurred:

• Name:

  Sign

• Detail any first-aid or medical treatment administered. (Provide names)

• Actions taken by TECSIDE (completed by TECSIDE Consultant)

• Is a Workers Compensation Claim being made?

  Yes

  No

  N/A

DETAILS OF DAMAGE, IF APPLICABLE

• Detailed description of incident. (Include environmental conditions at time of incident)

• Property Damage:

  None

  Minor

  Serious

  Major

• Photo of damage.

  Media

• Environmental photo:

  Media

• Illustrated incident (if possible):

  Drawing

Witness Statement

• Date of injury/incident:

  Date

• Name of witness:

• Witness statement of events

• (Witness) Please print name, sign and date the above statement as a true account of what occurred:

• Signature of witness:

  Sign

Contributing factors and root cause of the Accident/ Incident / Hazard / Near Miss: (any 'No' answers will be a contributing factor)

• Person:

• Aware of the hazard?

  Yes

  No

  N/A

• Suitable for the task?

  Yes

  No

  N/A

• Experienced at the task?

  Yes

  No

  N/A

• Familiar with the work area?

  Yes

  No

  N/A

• Inducted to the site?

  Yes

  No

  N/A

• Using appropriate PPE?

  Yes

  No

  N/A

• Environment:

• Adequate temperature conditions?

  Yes

  No

  N/A

• Adequate lighting?

  Yes

  No

  N/A

• Adequate working space?

  Yes

  No

  N/A

• Clear floor and walkways?

  Yes

  No

  N/A

• Adequate housekeeping?

  Yes

  No

  N/A

• Safe noise level?

  Yes

  No

  N/A

• Equipment:

• Equipment, tools or materials working properly?

  Yes

  No

  N/A

• Correct use of equipment?

  Yes

  No

  N/A

• Preventative maintenance carried out?

  Yes

  No

  N/A

• Equipment had not been modified?

  Yes

  No

  N/A

• Equipment guarded?

  Yes

  No

  N/A

• Job / Task

• Did the client provide training?

  Yes

  No

  N/A

• Supervision provided?

  Yes

  No

  N/A

• Job Analysis performed?

  Yes

  No

  N/A

• Written work procedures available?

  Yes

  No

  N/A

• Task not modified / changed?

  Yes

  No

  N/A

• PPE provided?

  Yes

  No

  N/A

• Enough time allowed?

  Yes

  No

  N/A

• Other contributing factors?

Recommendations

• Can the risk be eliminated? If yes, why or how:

  Yes

  No

  N/A

• Can equipment or materials be substituted? If yes, why or how:

  Yes

  No

  N/A

• Can engineering solutions be adopted? If yes, why or how:

  Yes

  No

  N/A

• Can administrative controls be developed? If yes, why or how:

  Yes

  No

  N/A

• Is PPE required? If yes, what type?

  Yes

  No

  N/A

Analysis and signatures

• Time line of events:

• Corrective Action (Include detail description of action and person(s) responsible for actions)

• Host employer signature:

  Sign

• TECSIDE representative signature:

  Sign