- NAVSTA 32
Site that employee was working at;
Nature of Incident or Injury
Describe who, what, when,where, why and how injury occurred:
Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following proper safety procedures and instructions)
Possible Cause or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilise safety equipment)
What is the employee's current status if injured: Describe. ( Returned to work the next day, off of work do to injury, off of work do to restrictions, In hospital, etc.)
Was Risk Assessment completed before work began:
Facility Safety Office Informed?
Where was the Medical treatment first provided?
Provider Doctor Details
Part of Body injured:
Will the employee have any restrictions:
What was the immediate action taken to correct the issue (how was this done):
What is the long term action needed to correct the issue:
Please provide all attachments that apply: Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other.
Injured employee has received Workers Compensation DWC-1 report