Incident/Accident and Investigation Report

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20 Tarlington Place, Smithfield, NSW 2164

Telephone: 02 9188 7285 FAX: E-mail: sales@rushexpress.com.au

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Incident/Accident and Investigation Report

Fill below:

INJURED PERSON'S DETAILS
Name of injured person
FirstLast
Area/Location
Position
Phone
[Please tick]
- Employee
- Contractor
- Company
DETAILS OF THE ACCIDENT
Date of the incident
Time
: HH
MM
Exact location of the incident
Operation the worker/contractor was engaged in at the time of the incident
DETAILS OF THE TREATMENT
What treatment was provided? [please tick]
- Nil
- First Aid
- Medical Practitioner
- Hospital
If you went to hospital or were seen by a medical practitioner, provide more detail (otherwise skip)
Details of treatment
Was there any time lost [please tick]
- Nil
- Remainder of the day
- Other
Workers Compensation claim lodged
- Yes
- No
ABOUT THE INJURY [ TICK APPROPRIATE BOX]
Cause of injury
- Pushing/Pulling
- Trip/slip/fall
- Falling object
- Vehicle
- Hit by
- Hit against
- Chemical
- Other
If other, explain
Nature of injury
- Cut
- Bruise
- Sprain/strain
- Electric shock
- Fracture
- Puncture
- Burn
- Abrasion
- Other
If other, explain
What body part was affected?
- Head
- Hand (right)
- Hand (left)
- Fingers
- Face
- Knee (right)
- Knee (left)
- Ankle (right)
- Ankle (left)
- Eye (right)
- Eye (left)
- Leg (right)
- Leg (left)
- Ankle (left)
- Nose
- Ears
- Back
- Neck
- Foot (right)
- Foot (left)
- Arm (right)
- Arm (left)
- Other
If other, explain
THE INCIDENT
Were there any witnesses? [please tick]
- Yes
- No
If yes, list names below
Name
FirstLast
Phone
Name
FirstLast
Phone
INCIDENT ANALYSIS
What contributed to the incident: [describe the factors that contributed to the incident]
Work Organisation
Work Methods
Work Environment
Work Equipment/Plant
Employees/Behaviour
Conclusions
PREVENTION
What was the IMMEDIATE action taken following the incident or accident?
What action will be taken to prevent a recurrence?
INVESTIGATION OF INCIDENT

Incident investigated by:
Name
FirstLast
Position
Date
Manager:
Name
FirstLast
Position
Date