WORKERS INJURY / INCIDENT INVESTIGATION REPORT FORM

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

SECTION 1: INJURED PERSON DETAILS

• Name:

• Age:

• Sex:

  Male

  Female

• Occupation / Job:

SECTION 2: DETAILS OF INCIDENT

• Date Incident Occurred and Time

  Date

• Date Incident Reported and Time:

  Date

• Reported To:

• Exact Location of Incident:

• Nature of Injury:

• Part of Body Injured:

• Treatment Given

  First Aid

  Medical

• After Injury the Person was sent to

  Doctor

  Physio

  Normal Duties

  Selected Duties

  Sent Home

• Treating First Aid Officer's Sigature:

  Sign

• Date:

  Date

• Describe how the Incident Occurred: The employee and/or witness states the following.

• Employee/Witness Signature:

  Sign

• Worker/Injured Persons Signature:

  Sign

SECTION 3: SUPERVISOR's/MANAGER's INVESTIGATION DETAILS (Attach photographs/sketches where relevant) [CONSIDER WHETHER LEGAL PRIVILEGE SHOULD BE OBTAINED BEFORE COMPLETING THIS SECTION]

• State the specific task/activity at time of incident:

• Pictures of job site area:

  Media

• Describe what task/activity the injured person was doing immediately before the incident:

• Was the incident site inspected following the incident?

  YES

  NO

CONTRIBUTING FACTORS (Events and conditions that contributed to the incident)

• Was the design, construction or use of plant/equipment a contributing factor?

  Yes

  No

  N/A

• Was a hazardous condition such as working environment, or the location of tools, equipment or materials, a contributing factor?

  Yes

  No

  N/A

• Was the management system that governed the above task and function defective?

  Yes

  No

  N/A

• Did personal/human factors influence the behaviour/actions of the individual?

  Yes

  No

  N/A

• Was the work method being performed a contributing factor?

  Yes

  No

  N/A

• Was lack of personal protective equipment a contributing factor?

  Yes

  No

  N/A

• Investigated By:

• Investigator's Signature:

  Sign

• Date / Time

  Date

SECTION 4: CORRECTIVE ACTION Explain what is required so that the problems that have been identified can be eliminated or effectively controlled.

• 1) Eliminate:

  Safe

  At Risk

  N/A

• 2) Replace / Substitute:

  Safe

  At Risk

  N/A

• 3) Redesign:

  Safe

  At Risk

  N/A

• 4) Administrative Controls (i.e. safe operating procedures, PPE):

  Safe

  At Risk

  N/A

• 5) Where required, has a risk assessment been conducted (i.e. plant safety, manual handling)?

  Safe

  At Risk

  N/A

PERSON(S) RESPONSIBLE FOR COMPLETING CORRECTIVE ACTION:

• Supervisor Signature & Name:

  Sign

SECTION 5): HEALTH & SAFETY MANAGER COMMENTS:

• Comments:

• Name & Signature:

  Sign

• Select date

  Date