USI Incident Report Form

• Document No.

• Company Name

• Client / Site

• Conducted on

  Date

• Prepared by

Details

• Company Name

• Contact Person

• Contact Phone Number

• Name of Person Completing This Form

• Employment Status of person involved in incident

  Select Employee Contractor Member of the Public Visitor Full Time Part Time Casual

  • Employee
  • Contractor
  • Member of the Public
  • Visitor
  • Full Time
  • Part Time
  • Casual

• Format Type being worked on during incident

  Posters

  Large Format

  Transit

  oOH!

  Private

• Sex of person involved in incident

  Male

  Female

• Date of Birth of person involved in incident

• Address of person involved in incident

• Occupation of person involved in incident

• Mobile Number of person involved in incident

• Does the incident involve a car?

  Yes

  No

• Please move onto next page

• Please carry on with the below

Non vehicular incident/accident

• Date and time of incident

• Date reported and who the incident was reported to

• Person in charge at scene of incident

• Location of incident (Suburb, State, Site number etc)

• Was there equipment involved in the incident?

• List equipment involved and detail it's impact on incident

• Were chemical substances involved in the incident?

• List chemicals involved

• Was the MSDS on site?

• Classification of incident type

  Select Journey incident Near miss/hit Medical treatment injury Property damage Work caused illness Dangerous event Environmental incident Lost time injury

  • Journey incident
  • Near miss/hit
  • Medical treatment injury
  • Property damage
  • Work caused illness
  • Dangerous event
  • Environmental incident
  • Lost time injury

• How much time is expected to be lost?

  Select Under 1 hour Half day Full day Under a week One week Two weeks One month Over a month

  • Under 1 hour
  • Half day
  • Full day
  • Under a week
  • One week
  • Two weeks
  • One month
  • Over a month

• Incident type

  Select Ergonomic Caught between objects Moving object (fall, strike it, it strike) Over exertion Awkward movement Vehicle incident Component / Equipment failure Exposure to impulse noise Exposure to prolonged noise Exposure to substance Slip, trip or fall a Repetitive movement Contact with energy source Contact with heat or cold Exposure to mental stress Other

  • Ergonomic
  • Caught between objects
  • Moving object (fall, strike it, it strike)
  • Over exertion
  • Awkward movement
  • Vehicle incident
  • Component / Equipment failure
  • Exposure to impulse noise
  • Exposure to prolonged noise
  • Exposure to substance
  • Slip, trip or fall
  • a Repetitive movement
  • Contact with energy source
  • Contact with heat or cold
  • Exposure to mental stress
  • Other

• Does your incident involve a motor vehicle?

  Yes

  No

• Please ensure previous page is completed

• Do not admit fault, tell any people involved to ring the office on 02 9648 4454

• Ring police immediately and begin filling in the form

USI vehicle details

• Enter date and time of accident

• Enter USI vehicle rego

• Enter USI drivers name

• Enter USI driver license number

• Enter details of damage to USI vehicle

• Enter photo of USI damage

  Media

• Enter passenger names of USI vehicle (if any were in the vehicle at the time of accident)

Other vehicle details

• Enter other vehicles drivers name and phone number

• Enter other vehicles drivers license number

• Is the driver the owner of the vehicle?

  Yes

  No

• Enter owners name

• Enter other vehicle drivers address

• Enter other vehicles rego plate details

• Enter colour, make and model of other vehicle

• Enter the insurance company of the other vehicle. Put N/A if uninsured

• Detail any damage to the other vehicle

• Insert phot of damage to the other vehicle

  Media

• Enter details from any passengers from the other vehicle. E.G. Name send number

Accident Details

• Date and time of accident

• Location of accident, include an address and cross street

• Detail weather conditions at time of accident

• Enter police details, name officer attending, time they arrived

• Detail how the accident happened

• Draw diagram of how the accident occurred

  Drawing

• Enter any injury details on next page and witness details on page after

Injury information person 1

• Name of injured person 1

• Location of injury (Person 1) tick all that apply

  Select left side of the body right side of the body Front of body back of body face/head Shoulder hip neck/upper back Upper arm Upper leg Lower back elbow knee Chest Lower arm/wrist Foot/toes lower leg/ankle Abdomen Hand/fingers internal injury, no visible injury

  • left side of the body
  • right side of the body
  • Front of body
  • back of body
  • face/head
  • Shoulder
  • hip
  • neck/upper back
  • Upper arm
  • Upper leg
  • Lower back
  • elbow
  • knee
  • Chest
  • Lower arm/wrist
  • Foot/toes
  • lower leg/ankle
  • Abdomen
  • Hand/fingers
  • internal injury, no visible injury

• Type of injury (person 1) tick all that apply

  Select Traumatic amputation Dislocation Concussion Strain/sprain Laceration Abrasion Puncture Foreign body Fracture Open wound Superficial injury Bruise Electric shock Burn/scold Animal/Insect Bite or Sting Shock Seizure Poison Internal injury Other

  • Traumatic amputation
  • Dislocation
  • Concussion
  • Strain/sprain
  • Laceration
  • Abrasion
  • Puncture
  • Foreign body
  • Fracture
  • Open wound
  • Superficial injury
  • Bruise
  • Electric shock
  • Burn/scold
  • Animal/Insect Bite or Sting
  • Shock
  • Seizure
  • Poison
  • Internal injury
  • Other

• List other injury

• Treatment type given to person 1

  First Aid

  Ambulace

  Medical Centre

  Hospital

• Name of treatment provider (address)

• Treatment details for person 1

Injury Details Person 2 (if required)

• Name of injured person 2

• Location of injury (Person 2) tick all that apply

  Select left side of the body right side of the body Front of body back of body face/head Shoulder hip neck/upper back Upper arm Upper leg Lower back elbow knee Chest Lower arm/wrist Foot/toes lower leg/ankle Abdomen Hand/fingers internal injury, no visible injury

  • left side of the body
  • right side of the body
  • Front of body
  • back of body
  • face/head
  • Shoulder
  • hip
  • neck/upper back
  • Upper arm
  • Upper leg
  • Lower back
  • elbow
  • knee
  • Chest
  • Lower arm/wrist
  • Foot/toes
  • lower leg/ankle
  • Abdomen
  • Hand/fingers
  • internal injury, no visible injury

• Type of injury (person 2) tick all that apply

  Select Traumatic amputation Dislocation Concussion Strain/sprain Laceration Abrasion Puncture Foreign body Fracture Open wound Superficial injury Bruise Electric shock Burn/scold Animal/Insect Bite or Sting Shock Seizure Poison Internal injury Other

  • Traumatic amputation
  • Dislocation
  • Concussion
  • Strain/sprain
  • Laceration
  • Abrasion
  • Puncture
  • Foreign body
  • Fracture
  • Open wound
  • Superficial injury
  • Bruise
  • Electric shock
  • Burn/scold
  • Animal/Insect Bite or Sting
  • Shock
  • Seizure
  • Poison
  • Internal injury
  • Other

• List other injury

• Treatment type given to person 2

  First Aid

  Ambulace

  Medical Centre

  Hospital

• Name of treatment provider (address)

• Treatment details for person 2

Injury Details Person 3 (if required)

• Name of injured person 3

• Location of injury (Person 3) tick all that apply

  Select left side of the body right side of the body Front of body back of body face/head Shoulder hip neck/upper back Upper arm Upper leg Lower back elbow knee Chest Lower arm/wrist Foot/toes lower leg/ankle Abdomen Hand/fingers internal injury, no visible injury

  • left side of the body
  • right side of the body
  • Front of body
  • back of body
  • face/head
  • Shoulder
  • hip
  • neck/upper back
  • Upper arm
  • Upper leg
  • Lower back
  • elbow
  • knee
  • Chest
  • Lower arm/wrist
  • Foot/toes
  • lower leg/ankle
  • Abdomen
  • Hand/fingers
  • internal injury, no visible injury

• Type of injury (person 3) tick all that apply

  Select Traumatic amputation Dislocation Concussion Strain/sprain Laceration Abrasion Puncture Foreign body Fracture Open wound Superficial injury Bruise Electric shock Burn/scold Animal/Insect Bite or Sting Shock Seizure Poison Internal injury Other

  • Traumatic amputation
  • Dislocation
  • Concussion
  • Strain/sprain
  • Laceration
  • Abrasion
  • Puncture
  • Foreign body
  • Fracture
  • Open wound
  • Superficial injury
  • Bruise
  • Electric shock
  • Burn/scold
  • Animal/Insect Bite or Sting
  • Shock
  • Seizure
  • Poison
  • Internal injury
  • Other

• List other injury

• Treatment type given to person 3

  First Aid

  Ambulace

  Medical Centre

  Hospital

• Name of treatment provider (address)

• Treatment details for person 3

Incident Description

• Describe the events leading up to the incident. How did the accident happen?

• What PPE was being used or worn at the time of the incident?

• What actions, if any, could have prevented this incident from occurring?

Witness details

• Name and phone number of witness 1

• Name and phone number of witness 2

• Name and phone number of witness 3

• Name and phone number of witness 4

• Name and phone number of witness 5

Incident Response

• What immediate actions were taken once the incident occurred? (Treatment of injured, hazard removal, securing the scene, who was called to attend the incident?)

Reporting and Notification

• Has this incident been reported to the client?

• Is this a notifiable incident?

• Call WorkCover on 13 10 50 on instruction of Operations Director

Management Investigation

• Summarise findings and observations as to dust has occurred and potential cause of incident

• Recommend preventative action

  Select Changes to induction training Equipment/Machinery Modification Job Redesign Change to on-going training Change to work procedure Component/Equipment Failure Equipment/Machinery Maintenance Issue Change to Work Environment Other action

  • Changes to induction training
  • Equipment/Machinery Modification
  • Job Redesign
  • Change to on-going training
  • Change to work procedure
  • Component/Equipment Failure
  • Equipment/Machinery Maintenance Issue
  • Change to Work Environment
  • Other action

• Describe other action to prevent future occurrence

• Full Incident Investigation Recommended

  Yes

  No

• Report prepared by (Enter name, position, date and time)

  Sign

• Report received by (Enter name, position, date and time)

  Sign