Incident Report
Incident Report
Incident Report
(TO BE COMPLETED AND SENT TO UWA SAFETY, HEALTH AND WELLBEING WITHIN 24 HOURS)
TO COMPLETE ON SCREEN - TAB BETWEEN FIELDS MAKING ENTRIES BY TYPING INTO THE GREY HIGHLIGHTED BOXES WHICH EXPAND AS REQUIRED
Last Name:
Gender:
Other names:
Student:
Contractor:
Date of Birth:
Visitor:
Occupation:
Staff/Student No:
Student:
Contractor:
Visitor:
Occupation:
Work phone:
Home:
Work phone:
Home:
Email:
Mobile:
Email:
Mobile:
Gender:
Title:
Other names:
Staff/Student
No:
Date of Birth:
Are you: Staff:
Last Name:
School / Centre:
School / Centre:
Home address:
Home address:
State:
Postcode:
State:
Postcode:
INCIDENT DETAILS - for electrical incidents, immediately also notify FM Technical Officer (Electrical) on (08) 6488 2031
or Building Services Electrical Supervisor on (08) 6488 2016
Incident
Injury
Exact Location:
Near miss
Illness/disease
Date of occurrence:
How did the incident/injury happen (please provide a step by step account):
Witness1:
Witnes
s2:
Phone:
Phone:
Noticed on Date:
None
Other:
Treatment Date:
Doctor
Nurse
First Aid
Time: (am /
pm)
Time: (am /
pm)
How notified:
Date Notified:
In
person
By
phone
By
email
Othe
r
How notified:
Date Notified:
In
person
By
phone
By
email
Othe
r
Version 2.0
Page 1 of 3
(TO BE COMPLETED AND SENT TO UWA SAFETY, HEALTH AND WELLBEING WITHIN FIVE WORKING DAYS)
TO COMPLETE ON SCREEN - TAB BETWEEN FIELDS MAKING ENTRIES BY TYPING INTO THE GREY HIGHLIGHTED BOXES WHICH EXPAND AS REQUIRED
If a UWA employee, does the injured person intend to lodge a workers compensation claim? Yes
No
Unknown
Yes
Indoors
No
If NO go to next section
Outdoors
(covered)
Dawn/Dusk
Outdoors
(uncovered
)
Daylight
Night
Steps /
Stairs
Walkway
*** PLEASE ATTACH A DIAGRAM OF WHERE THE SLIP / TRIP / FALL OCCURRED, SHOWING EXACT LOCATION, IF APPROPRIATE ***
Type of surface:
Carpet
Cement
Gravel
Road
Rocks
Other (explain):
Bending
Catching
Pulling
Pushing
Damaged
Dry
Sand
Tile
Footpat
h
Torn
High heels
None
Open
Walking
Wet
Sandals
Descending
Back
Yes
Ascending
Front
Side
Details:
If YES complete below
If NO go to next section
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Load height:
Distance carried:
Lowerin
Carrying
Kneeling
Lifting
g
Reaching
Sitting
Stooping
Twisting
Grass
If NO go to next section
No
Last service date:
No
N/A
No
N/A
If YES complete below
If NO go to next section
No
N/A
No
N/A
No
Date completed:
TICK BOXES TO INDICATE IF ANY OF THE FOLLOWING FACTORS CONTRIBUTED TO THE INCIDENT:
Environment workplace/task design
Inadequate supervision
Failure to follow work procedures
Inadequate training
Improper use/storage of materials
Personal Protective Equipment inappropriate/not used
Inadequate equipment function
Lack of experience in task/not competent
Inadequate equipment maintenance
Poor/lack of suitable equipment
Inadequate safety procedures
Untidy work area
Inadequate space
Personal factors
Environmental conditions
(e.g. stress, fatigue, pre-existing medical condition)
(e.g. weather, lighting, ventilation, temperature)
Confidential Incident / Injury / Near Miss Report - Supervisor / Manager Investigation
Version 2.0
Page 2 of 3
(TO BE COMPLETED AND SENT TO UWA SAFETY, HEALTH AND WELLBEING WITHIN FIVE WORKING DAYS)
TO COMPLETE ON SCREEN - TAB BETWEEN FIELDS MAKING ENTRIES BY TYPING INTO THE GREY HIGHLIGHTED BOXES WHICH EXPAND AS REQUIRED
Other (explain):
INCIDENT / INJURY:
Please provide detail of what injured person was doing prior to the incident and what tools or equipment were being used:
A hierarchy of control should be used to assist with the prevention of future similar injuries. The hierarchy of control depicts the most to
the least effective methods, as shown in the table below. Please complete all sections.
RECOMMENDATIONS TO PREVENT REOCCURENCE OF THIS HAZARD:
RISK CONTROL
OPTIONS
REQUIRED ACTION
BY WHOM
BY WHEN
Elimination (e.g.
remove)
Substitution (e.g.
alternate)
Engineering (e.g.
controls/guards)
Administration (e.g.
standard operating
procedures,
training)
Personal Protective
Equipment (e.g.
safety glasses,
helmets, gloves)
Date:
Mailbag:
Manager/Supervisor name:
Signature:
Phone:
Phone:
Date:
Mailbag:
Phone:
Date:
Mailbag:
Signature:
Yes
Signature:
No
Date:
Version 2.0
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