Incident report form – Perth Limestone Specialists

This form is to be completed in the event of a worker being involved in or witnessing any incident that has resulted in an injury to a person that requires or required more than basic first-aid.

The form should also be used to report an incident, a major non-conformance, unsafe practice or a near miss/hit that could have resulted in a serious injury.

DETAILS OF PERSON COMPLETING INCIDENT REPORT

First name

Last name

Position

DETAILS OF PRIMARY PERSON INVOLVED IN INCIDENT

First name

Last name

DOB

Address

Phone number

Position

Supervisors name

DETAILS OF INCIDENT

Date of incident

Time of incident

Description of incident (In your own words, what happened?)

Location of incident

NAME/S OF WITNESSES

Name 1

Contact

Name 2

Contact

Name 3

Contact

DETAILS OF INJURIES SUSTAINED (Optional)

Injured persons name

Type of injury

Treatment received

Injured persons name

Type of injury

Treatment received

WAS ANY PROPERTY DAMAGED DURING INCIDENT

If yes, please detail:

DETAILS OF OTHER PERSONS INVOLVED

Did the incident involve any other persons?

YesNo

If yes, please provide details (eg. Name, contact, employer...)

INCIDENT SAFETY/SECURITY

Has the area of the incident been secured to prevent unauthorised access?

YesNo

Are/were immediate corrective actions required to render the area safe or to eliminate or minimise an immediate risk?

YesNo

If yes, please describe; what needs/needed to be done, who is responsible for the task/s and when task/s will be/were completed

Name of person authorising actions to make incident area safe and secure.

Box to be checked only by the person authorising/authorised actions to make the area safe and secure.

OTHER DETAILS

Were emergency services involved? If yes, please provide details (eg. Type, id badge numbers...)

YesNo

Was Worksafe informed?

YesNo

Does the incident require notification to Worksafe?

YesNoNot sure

Was this a workers compensation related incident?

YesNo

Has the workers compensation insurer been notified?

YesNo

Is an internal incident investigation required?

YesNoNot sure

ADDITIONAL CORRECTIVE ACTIONS (Completed when internal investigation is not required)

Change to induction/toolbox

ProposedTaken

Change to ongoing training

ProposedTaken

Change to work procedure

ProposedTaken

Change to work environment

ProposedTaken

Equipment maintenances

ProposedTaken

Job redesign/restructure

ProposedTaken

Site cleanup

ProposedTaken

Risk assessment review

ProposedTaken

Risk controls review

ProposedTaken

Other preventative action

ProposedTaken

PHOTOS - If you can, choose a MEDIUM file size for faster submission, without reduction of quality.

Photo description

Name of person authorising/submitting proposal of corrective actions

Box to be checked only by the person authorising/authorised/submitting proposal of; corrective actions.

Box to be checked only by the person completing this document. By ticking this box the author confirms that the details documented on this form are true and correct to the best of their knowledge.