"Incident Report Template"

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INCIDENT REPORT
1.
Staff
Teacher
Organiser
Volunteer
Student
2.
Incident Category
Notification – Nil Injury
Dancing Related Illness
Fatality
Near Miss
Dancing Related Injury
Dangerous Event
Serious Bodily Injury
Electrical Incident
Security
3.
Personal Data
Surname
Date of Birth
Given Names
Gender
4.
Affiliation Data Category of Person
Paid/Volunteer
Person in charge of location
Telephone
Starting date and time
Intended finishing date and time
5.
Incident Details
)
(if insufficient room attach details/diagram/drawing
Location of Incident
(exactly where did the incident occur)
Date and time of the Incident
Date and Time Reported
Reported to Name
Position
Witness Name
Witness Name
What happened unexpectedly?
How exactly did/could the illness, injury or damage happen?
Experience in task
years
Injury/Illness
Head
General
Slip or trip
Eye
Computer/keyboard use
Fall from height/ same
(classification)
level
Ear
Administration
Brain injury/ concussion
Hitting moving/
Mouth
Driving/riding
Fracture
stationary object
Nose
Walking/running
Wound/laceration/
Hit by moving object
Face
Dancing
contusion/bruising
Assault by person(s)
Neck
General Duties
Amputation
Tendon/muscular stress
Back: upper/lower
Manual Handling
Sharp/needle puncture
Repetitive movement
Chest
Lifting/carrying
Internal injury
Vehicle accident
Abdomen/pelvic
Push/pulling
Burn
Harassment/ bullying
Shoulder
Twisting/bending
Nerve/spinal injury
Work pressure
Upper arm/elbow/
Reaching
Joint/ligament/
Exposure/contact with:
Forearm
Repeated Movements
muscle/tendon injury
Mental stress factors
Wrist
Machinery/ equipment
Ear/eye/nose injury
Heat/cold
Hand/fingers/
Poisoning
Thumb
Sound/pressure
Electrocution
Hip
Chemical/substance
Musculoskeletal disease
Upper/low leg
Radiation
Mental illness/stress
Knee
Electricity
Digestive system
Ankle/foot/toe
Animal/insect
Skin disease/ dermatitis
Circulatory/
Biological factors
Nervous system/ sense
respiratory/digestive/
Other:
organ diseases
nervous system
Respiratory disease
Psychological
Heart/circulatory
Nil
Infection/virus
Cancer/melanoma
Nil injury
Action at the Time
What Happened
Prime Cause
(task involved)
(mechanism)
(agency)
Body Part Affected
(location)
Workers’ Compensation
6.
- Will a Work Cover claim be submitted for this incident? Yes No Unsure
Completed by
7.
Signature
Name
Date
INCIDENT REPORT
1.
Staff
Teacher
Organiser
Volunteer
Student
2.
Incident Category
Notification – Nil Injury
Dancing Related Illness
Fatality
Near Miss
Dancing Related Injury
Dangerous Event
Serious Bodily Injury
Electrical Incident
Security
3.
Personal Data
Surname
Date of Birth
Given Names
Gender
4.
Affiliation Data Category of Person
Paid/Volunteer
Person in charge of location
Telephone
Starting date and time
Intended finishing date and time
5.
Incident Details
)
(if insufficient room attach details/diagram/drawing
Location of Incident
(exactly where did the incident occur)
Date and time of the Incident
Date and Time Reported
Reported to Name
Position
Witness Name
Witness Name
What happened unexpectedly?
How exactly did/could the illness, injury or damage happen?
Experience in task
years
Injury/Illness
Head
General
Slip or trip
Eye
Computer/keyboard use
Fall from height/ same
(classification)
level
Ear
Administration
Brain injury/ concussion
Hitting moving/
Mouth
Driving/riding
Fracture
stationary object
Nose
Walking/running
Wound/laceration/
Hit by moving object
Face
Dancing
contusion/bruising
Assault by person(s)
Neck
General Duties
Amputation
Tendon/muscular stress
Back: upper/lower
Manual Handling
Sharp/needle puncture
Repetitive movement
Chest
Lifting/carrying
Internal injury
Vehicle accident
Abdomen/pelvic
Push/pulling
Burn
Harassment/ bullying
Shoulder
Twisting/bending
Nerve/spinal injury
Work pressure
Upper arm/elbow/
Reaching
Joint/ligament/
Exposure/contact with:
Forearm
Repeated Movements
muscle/tendon injury
Mental stress factors
Wrist
Machinery/ equipment
Ear/eye/nose injury
Heat/cold
Hand/fingers/
Poisoning
Thumb
Sound/pressure
Electrocution
Hip
Chemical/substance
Musculoskeletal disease
Upper/low leg
Radiation
Mental illness/stress
Knee
Electricity
Digestive system
Ankle/foot/toe
Animal/insect
Skin disease/ dermatitis
Circulatory/
Biological factors
Nervous system/ sense
respiratory/digestive/
Other:
organ diseases
nervous system
Respiratory disease
Psychological
Heart/circulatory
Nil
Infection/virus
Cancer/melanoma
Nil injury
Action at the Time
What Happened
Prime Cause
(task involved)
(mechanism)
(agency)
Body Part Affected
(location)
Workers’ Compensation
6.
- Will a Work Cover claim be submitted for this incident? Yes No Unsure
Completed by
7.
Signature
Name
Date
Risk Rating
8.
Please refer to the Workplace Incident Report Form Procedures for instructions on how to complete the risk matrix
below.
Consequence
Negligible
Minor
Moderate
Major
Extreme
No injury/
Injury or
Serious
Fatality
Multiple
Likelihood
illness – no
illness
Injury/ Illness
Fatality
lost time
requiring
- > 4 days lost
first aid only
or event that
– lost time of
is notifiable
< 4 days
Rare May only occur in exceptional circumstances
Low
Low
Low
Medium
High
Unlikely Might occur at least once (not to be expected)
Low
Medium
Medium
High
Very High
Possible Could occur at least once (capable of
Low
Medium
High
Very High
Very High
happening/foreseeable)
Likely Is expected to occur occasionally (to be expected)
Medium
High
Very High
Very High
Extreme
Almost Certain Is expected to occur frequently (in most
Medium
Very High
Very High
Extreme
Extreme
circumstances)
Risk Rating
Eg. If you had a likelihood of possible and a consequence of minor, the risk rating would be medium.
IF THE RISK RATING IS “VERY HIGH” OR “EXTREME”, OR THE CONSEQUENCES ARE “MAJOR” OR “EXTREME” NOTIFY WORKPLACE HEALTH AND SAFTEY
UNIT IMMEDIATELY
NOW HAND THIS FORM TO PRINCIPAL TEACHER/ COMPETITION ORGANISER OR EVENTS MANAGER
INCIDENT INVESTIGATION
9.
Management Review
What task was being performed at the time of incident? (If insufficient room attach details)
Has a similar event occurred within this work area in the past 6 months?
Yes
No
If YES what was done to prevent recurrence?
From our review, indicate the prime cause of the incident:
Unsafe equipment or plant
Work area unsuitable/unsafe
Hazard not risk assessed
Correct procedure not applied to tasks
Performer or audience action
Worker inexperience
Appropriate procedure non existent
Workload factors
Supervision lacking
Unsafe work practices in use
Staff training inappropriate
Inappropriate equipment in use
Hazard(s) not identified
Work practices not defined
Incidents not reviewed
PPE not used
Work practice review not done
Work area security deficient
Safe work practices not enforced
Fatigue
Other
Was time off required?
Yes
No
If yes indicate:
<1 day
>than 1 day
(how many)
Was treatment required?
Nil
First Aid
DEM/OH/GP Treatment
Hospitalisation
Blood/Body Fluid Protocol
What action do you, as the Principal Teacher/Competition Organiser or Events Manager intend to take to prevent recurrence:
Corrective Action
Action Required and Task(s) Allocated to
Action by Date
Date Completed
Change to work practices
Change to work area layout/design
Debriefing or counselling
Undertake task analysis or risk assessment
Submit equipment maintenance requisition
Review staff training
Seek WH&S input to identify preventive controls
Refer to Executive for decision/guidance
Nil Action required
Other
Has the person reporting the incident been advised of actions taken to prevent recurrence?
Yes
No
Date Notified
By Whom
Signature
Name and Position
Date
10.
Department Head Comment
Do you concur with the Manager/Supervisor’s review and recommended corrective action?
Yes
No
Signature
Name and Position
Date
11.
WH&S Comments
Is further investigation required?
Yes
No
Signature
Name
Date
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