Accident /Incident/Injury Report & Investigation Form Incident Details: Location/s of Incident: Address of Incident: Person Involved Details: Person Involved: Witness Name (If Applicable): Time of Incident Type Of Works: Civil Construction Maintenance Telecommunications Road Setup: Lane Closure Contraflow Highway Setup Company Affiliation: Employee Contracting Company Name: Description Of Incident Photos of Incident Attached Or Given To Supervisor: Date of Incident: Date Reported: Time Reported Electrical Vegetation Services Highway Works Multiple Lane Closure Shoulder Closure Gate Keeping Sub-Contractor Type Of Report Injury Environmental Customer Complaint Injury Type (If Applicable) Lost Time Injury (LTI) Medical Treatment Injury (MTI) Nature Of Injury (If Applicable) Fracture Dislocation Sprains and Strains Cuts & Abrasions Bites & Stings Mechanism Of Injury Manual Handling Slips, Trips & Falls Noise Bites & Stings Body Location: Feet/Ankles/Toes Knee/Leg/Hips Chest & Abdominal Shoulders & Arms Hands & Fingers Incident Plant & Equipment Near Miss First Aid Injury (FAI) Injury No Treatment (INT) Foreign Body on Eye, in Ear or Nose Burns Poisoning Electrocution Falling Objects Vehicle PPE Incorrect or Not Used Contact With Foreign Object/s Face/Head/Neck Back Eyes Multiple Locations v1.4 March 2016 Review December 2016 Page 1 of 5
What Was The Person Doing At The Time Of The Incident: Persons Involved/Recommendations: What Actions/Procedures Could Be Taken To Prevent This Incident From Reoccurring? Plant/Equipment Details (If Applicable): Vehicle Equipment Other Make: Model: Registration: Vehicle Specifics (If Applicable): Was The Activity Part Of Normal Duties: Was The Incident Reported To The Police: Damage To Vehicle Details: Damage To Vehicle Overview (If Applicable): v1.4 March 2016 Review December 2016 Page 2 of 5
Sketch The Incident: Draw intersection or street on diagram 1. Show speeds of vehicles 2. Show vehicle and direction of travel as A 3. Show vehicle A and direction of travel as B 4. 5. Show Street names 6. Show Intersection Controls e.g: 7. Show directional lane arrows Example: A A B 15km/hr v1.4 March 2016 Review December 2016 Page 3 of 5
Immediate/Temporary Controls Needed: Incident Category / Refer To Risk Matrix Actual Incident Score: Potential Incident Score: Red Area DO NOT START WORKS, Review controls, Contact Supervisor and Senior Management. All controls need to be implemented, an onsite Risk Assessment and Start Card need to be completed and discussed Yellow Area prior to start. All controls and measures need to be checked and monitored throughout the day. Site supervisors will need to be advised of work setup (Including changes) Blue Area Standard Work Procedures Apply; Control by Routine Measures. C = Consequence L = Likelihood Hierarchy Of Control 5 = Catastrophic. Death, disablement, significant incident, unacceptable risk, significant financial cost. 4 = Major. Extensive injuries leading to lost time, major risk-damage to plant and equipment, major financial cost for repairs / reinstatement. 3 = Moderate. Medical treatment, medium risk-damage to plant and equipment, medium financial cost for repairs / reinstatement. 2 = Minor. First Aid treatment, minor risk-damage to plant and equipment, minor financial cost for repairs / reinstatement. 1 = Insignificant: No injuries, slight damage, low financial cost for repairs / reinstatement. C x L = R 5 = Almost Certain. Could occur in most circumstances. 4 = Likely. May probably occur in most circumstances. 3 = Possible. May occur at some time. 2 = Unlikely. Could occur at some time. 1 = Rare. May occur only in exceptional circumstances. C = Consequences 1 = Elimination. Modify the process method or material to eliminate the hazard completely. 2 = Substitution. Replace the material, substance or process with a less hazardous one. 3 = Isolate. Isolate the hazard from the person by safeguarding or by space or time. 4 = Redesign / Engineering Controls. Redesign or modify the plant or process to reduce or eliminate the risk 5 = Isolation Isolation of the hazard. 6 = PPE & Administration Use appropriately designed and properly fitted equipment where other controls are not practicable or are accepted. Adjust the exposure time or conditions or process by training, procedure, signs etc. L = Likelihood 5 = Catastrophic 4 = Major 3 = Moderate 2 = Minor 1 = Insignificant 5 = Almost Certain 25 20 15 10 5 4 = Likely 20 16 12 8 4 3 = Possible 15 12 9 6 3 2 = Unlikely 10 8 6 4 2 1 = Rare 5 4 3 2 1 Root Causes Of Of Incident (If Applicable Tick Multiple): Job/Safety Factors Instructions/Training Design/Setup Work Procedures Tools/Equipment Maintenance Wear & Tear Abuse Of Misuse PPE Horseplay Leadership/Supervision Environmental Forward Sections Must Be Completed By Employer: Did The Injured Person Stop Work: Yes Treated by doctor Workers compensation claim Alternative duties No Hospitalised Returned to normal work Rehabilitation v1.4 March 2016 Review December 2016 Page 4 of 5
Photos OF Incident/Injury Please Attach Photos Here Incident Investigations (To Include ALL Comments & Factors) Risk Assessment: Likelihood Of Recurrence: Severity Of Outcome: Level Of Risk: Actions To Prevent Reoccurrences: Action By Whom By When Date Completed Actions Completed: Signed (Manager): Review Comments: Staff Toolbox Required: Site Manager Reviewed (Signed): Health & Safety Representative (Signed): Title: Time: v1.4 March 2016 Review December 2016 Page 5 of 5