Incident Report Form "*" indicates required fields REPORT FORM Injury / Incident / Near Miss This form is to be used to report all injuries, illnesses, or near misses, whether an injury occurred or not, and to document the investigation into the accidents by the Occupational Health and Safety representative involved.Please complete within 24 hours of the accident. If the accident caused, or could have caused, serious injury or property damage, please contact the Human Resources Department immediately.Section ATO BE COMPLETED BY PERSON INVOLVED (or by Occupational Health and Safety Officer if worker is incapacitated).Person Involved in the Accident/Incident*Full name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Name Surname Date of Birth* Your Role* Staff Volunteer Contractor Visitor/Other Gender* Male Female Other Department*Position*Contact Telephone Number*Details of the Event*Please choose appropriate Injury Incident Near miss Date injury/incident/near miss occurred* Time injury/incident/near miss occurred* Hours : Minutes AM PM AM/PM Location where injury/incident occurred*Part(s) of body affected (tick appropriate answers)Head Eye Ear Nose Mouth Teeth Face Skull Trunk Neck Hip Chest Stomach Groin Back Multiple Internal Heart Lungs Systemic Arm Left Right Shoulder Upper Arm Elbow Forearm Wrist Hand Left Right Thumb Fingers Palm Leg Left Right Knee Lower leg Ankle Thigh Upper leg Foot Left Right Great toe Other toes No injury to body No injury applicable Nature of Injury*Tick appropriate answer(s) Abrasion Bruise Fracture Concussion Puncture Laceration Amputation Bite Heart attack Hearing loss Foreign body Minor cuts Sprain Strain Hernia Burn Scald Rash Allergy Traumatic shock Electric shock Psychosocial Chemical Aggravation of previous injury or medical condition Not applicable Type of Incident which caused Injury*Tick appropriate answer(s) Striking against Struck by Caught in Stepping on Stumbling Slipping Tripping Falling Lifting Bending Twisting Stress Pushing Pulling Jumping Motor vehicle Ingestion Absorption Inhalation Needlestick Other Not applicable Describe the incident*Agency of injury/illness/near miss*Tick appropriate answer(s) Vehicle Power tools Animal/insect Biological agent Objects Buildings Furniture Heat stress Chemicals Ionising radiation Mobile plant Other tools Materials Equipment Structures Surfaces Sunburn Stress Other Not applicable If reporting an incident or near miss, please describe how this occurredSection BTO BE COMPLETED BY THE OCCUPATIONAL HEALTH AND SAFETY REPRESENTATIVE AND THE PERSON INVOLVED WITHIN 48 HRS.This is an extremely important section as the aim of the accident/incident/near miss investigation is to identify preventative action that will avoid recurrence of a similar accident.Probable cause or causes of injury/incident/near miss*Tick appropriate answer(s) Inadequate instruction Inadequate workspace Assistance unavailable Fault of plant or equipment Equipment unavailable Lack of attention Poor storage Poor access Incorrect method Weather Terrain Work practices Describe how the incident occurred*PREVENTION OF ACCIDENT/INCIDENT/NEAR MISS RECURRENCEDescribe what action is planned or has been taken to prevent a recurrence of the accident, based on the key contributing factors:Immediate action*Long-term action*Section CSignature by Supervisor*Your NameYour NameYour NameYour NameSupervisor's Name* First Name Surname Signed by Person Involved*Your NameYour NameYour NameYour NameSigned by OH&S Officer*Your NameYour NameYour NameYour Name Δ
