F53. Incident Investigation

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Unique ID

Incident Report

Report Date

DD slash MM slash YYYY

Project Name

On-site location

Interviewing Person

Location/address of Site

Date of Incident

DD slash MM slash YYYY

Time of Incident

Hours

:

Minutes

AM/PM

Day of week on which incident occurred

Witnesses (Staff Name)

Witnesses (Contractor Name)

The incident occurred

inside the building

outside of the building

site wide

Other

If the incident occurred outside, what was the weather?

sunny

raining

windy

overcast

dusty

frost

snow

sleeting

Type of Incident

Death

Machinery damage

Interruption to work

Personal Injury

Environmental damage

Property damage

Incident Investigation

Incident Classification

Questions

Chemical Spill or loss of Chemical

Yes

No

Caused by:

Other loss or damage:

Did this situation have the potential to cause harm?

Yes

No

Name and role title of party who approved work to commence:

Role

Details of immediate/temporary controls implemented:

General information

Who was the first person at the accident?

Was anyone working with the injured person?

Yes

No

Who was working with the injured person?

Name

Contact

Has an incident notification been completed?

Yes

No

Who administered first aid?

Was medical attention required?

Yes

No

Was the worker admitted to hospital?

Yes

No

When is the worker expected to return to work?

DD slash MM slash YYYY

Are safe housekeeping practices followed?

Yes

No

Task

Has the worker performed this task before?

Yes

No

How long?

What task was being performed?

Is there a written standard procedure?

Yes

No

If so, was it followed?

Yes

No

Is there a need for a new procedure?

Yes

No

Does the worker have a current valid VOC?

Yes

No

Validator of VOC (Name)

Contact

Was a risk assessment conducted and approved?

Yes

No

Approval of risk assessment (Name)

Contact

Supervision

Was the worker supervised?

Yes

No

Supervisor(Name)

Contact

Is there evidence of supervision?

Yes

No

Provide details of evidence – Upload document / photo

Were safety inspections conducted?

Yes

No

Safety inspections conducted by:(Name)

Contact

What issues were found by the inspection?

Were the issues addressed?

Yes

No

Details of those who addressed issues:(Name)

Contact

Was management informed?

Yes

No

Informed management: (Name)

Contact

Equipment

What was the equipment being used?

Equipment Type

Confirm it was in good condition

Yes

No

Provide Details

Prestart conducted by: (Name)

Contact

Manufacturer’s instructions, & SOP available?

Yes

No

Where are they located?

Other Details

Is the maintenance up to date?

Yes

No

Was the operator deemed as competent?

Yes

No

Approved competence (Name)

Contact

Environmental damage

What environmental damage was sustained?

What environmental damage was sustained? - Upload document / photo

Did Control Plan address the issues?

Yes

No

Have temporary controls been installed?

Yes

No

Evidence Gathered

Statements obtained - Upload document / photo

Contact

Photographs included:

Subject of photograph

Upload document / photo

Other Evidence:

Description

Upload document / photo

WHS Management System

OH&S management system address this issue?

Yes

No

Has the Management System been reviewed?

Yes

No

Reviewer of management system: (Name)

Contact

Have previous reports been considered?

Yes

No

Reviewer of previous reports

Contact

In your opinion what contributed directly to the incident:

Findings/Action Required

Comment for what to fix

What further training is required?

Is more supervision required?

Yes

No

Are SOP required to be updated or written?

Yes

No

HSR to be elected and consultation undertaken?

Yes

No

Should our Management System be reviewed?

Yes

No

Expected completion

DD slash MM slash YYYY

Incident Report

Incident Investigation

Questions

General information

Task

Supervision

Equipment

Environmental damage

Evidence Gathered

WHS Management System

Findings/Action Required

Section Break