Information
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Incident Record (ie [campus]_[date]_[surname of injured person]) for example: southport_03march2016_jones
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Date of this report
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Person completing report
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Indicate if reporting an "injury" or "near miss"
Description of Incident
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Date of Incident
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Time of Incident
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Date Reported
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Time Reported
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Location of Incident
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Detailed description of incident
Injured Person Details
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Details of Injured Person
- Employee
- Student
- Visitor
- Volunteer
- Client
- Contractor
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If injured person is a student, indicate, student type
- Apprentice
- School-based
- International
- Domestic
- Voc Placement
- Other
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Name of Injured Person
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Business Unit of Injured Person
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Employee/Student Number
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Date of Birth
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Contact Telephone Numbers
Injury Details
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Nature of Injury
- Fractures
- Back Injury
- Dislocation
- Sprain, strain
- Head injury or concussion
- Internal injury of chest, abdomen, pelvis
- Traumatic amputation or loss of eye
- Open wound
- Superficial injury
- Contusion or crushing injury
- Foreign body in eye, ear, nose or other
- Burns
- Injury to nerves and spinal cord
- Poisoning and toxic effects of substances
- Effects of weather, air pressure, contact with electricity, drowning or other external causes
- Multiple Injuries (no principal injury)
- Damage to artificial aids
- Other and unspecified injuries
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Nature of Disease
- Deafness
- Eye disorders
- Dermatitis/Other skin diseases
- Hernia
- Infectious disease
- Mental disorder
- Other diseases
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Bodily location of injury
- Eye
- Ear
- Face
- Head
- Neck
- Back
- Trunk
- Shoulders and Arms
- Hands and Fingers
- Hips and Legs
- Feet and Toes
- Internal Organs
- Multiple locations
- General and unspecified locations (eg skin, disease, mental disorder)
Injury Treatment
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Treatment provided to injured/ill person (mark all that apply)
- Treated by First Aid
- Referred to Doctor
- Unfit for work/returned home
- Returned to work/class
- Referred to hospital
- Returned to alternate duties
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If first aid treatment provided, provide details (inlcuding description of treatment, who provided treatment)
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Transported to Doctor/Hospital
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If transported to Doctor/Hospital, provide details of method of transport
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If transported to Doctor/Hospital, provide details of location
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Was this a lost-time injury (other than on the day of the incident)?
Reporting Details
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Provide details of who injury, incident or near miss was reported to (include name, position and contact number)
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Provide details of any witnesses to the injury, incident or near miss (include name and contact details for each)
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Provide details of person in charge of team/area (include name, position and contact number)
Signatures
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Signature of Injured Person
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Signature of Reporting Person
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Signature of Manager
For Completion by Investigating Officer Only
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Class A Incident (comprehensive investigation by H&S Investigator Definition: Serious injury - fatal or non-fatal Dangerous incident Work caused illness Serious electrial incident Action: immediately notify General Manager/CEO If applicable, notify WSHQ or ESO Investigate immediately
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Class B Incident (investigation by H&S Investigator) Definition: Significant injury Significant near miss or issue Action: Investigate within 2 working days
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Class C Incident (investigation by Manager) Definition: minor injury or incident minor near miss or issue Action: investigate within 3 working days
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Class P Incident (investigation by HR Manager) Definition: Psychological-related incident/injury/issue Action: Notify HR team for investigation and management
Investigation Details
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Mechanism of Injury
- Fall from height
- Fall on same level (eg slips, trips)
- Hitting objects with part of body
- Exposure to mechanical vibration
- Being hit by moving object
- Exposure to sharp, sudden sound
- Long term exposure to sounds
- Exposure to variations in pressure
- Repetitive movement - low muscle loading
- Other muscular stress
- Contact with electricity
- Contact/exposure to heat/cold
- Exposure to radiation
- Single contact with chemical or substance
- Long-term contact with chemical or substance (includes insect/spider bites/stings)
- Contact/exposure - biological hazards
- Exposure to mental stress
- Slide or cave in
- Vehicle accident
- Other and multiple mechanisms of injury
- Unspecified mechanisms of injury
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Agency of Injury
- Machinery and fixed plant
- Mobile plant
- Road transport
- Other transport
- Powered equipment, tools, appliance
- Non-powered hand tools
- Non-powered equipment
- Chemicals
- Non-metallic substances (eg gas)
- Other materials, substances or objects
- Outdoor environment
- Indoor environment
- Underground environment
- Live animals
- Non-living animals
- Human agencies
- Biological agencies
- Non-physical agencies
- Other agencies
- Unspecified agencies
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Work Related or Non-Work Related
Investigation Report
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What was happening at the time of the incident/near miss?
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What happened unexpectedly?
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How did the incident/near miss occur?
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What were the underlying factors which caused the incident, injury or near miss? (include contributing factors and root causes)
Corrective Actions
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Include details of Corrective Actions Required to Prevent this Incident occurring again. Include: - control measure - timeframe for implementing control - accountable person/team for implementing control - any other comments
Investigation Sign-Off
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investigating Officer Signature:
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Work Unit Manager Signature:
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WHS Co-ordinator Signature:
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Executive Director, People, Culture & Communication signature (for Cat A, B & P incidents)
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General Manager Signature (for Cat. A, B & P incidents)
