ACCIDENT REPORT FORM - IDCACCIDENT REPORTPlease complete this form (within 24 hrs) if an incident has occurred at work causing personal injury, property damage or near miss. PART A – DETAILS OF PERSON INVOLVEDBusiness Name & LocationNameFirst NameLast NamePositionEmployment Status Full Time Casual Contractor Visitor General Public Witnesses (if any): Name Position PART B - INCIDENT CLASSIFICATION & NOTIFICATION Please tick () the appropriate boxPersonal Injury Minor Injury Medical Expense Claim Lost Time Injury Journey Claim Property Damage Minor Damage > $1,000 (approx) Medium Damage $1,000 - $10,000 (approx) Major Damage >$10,000 (approx)Near Miss Low Potential Medium Potential High PotentialIs Worker Rehabilitation required? Yes NoOther - WhomInjury Identification - Part of Body Injured:Injury Identification - Type of Injury:WH&S notified? Yes NoWH&S notified - WhomDate & TimeElectrical Entity notified? Yes NoElectrical Entity notified? - WhomDate & TimePART C – REPORT DETAILSIncident Reported to - Name:Incident Reported to - Position: Date & Time Reported:Report Completed bySignature: Signature: DatePART E – INJURY CODE (Use for Part B)Description:Signature of Injured Person Sign Here DatePART D – INJURED PERSON’S DESCRIPTION OF INCIDENTNature of injury: (most serious one) Abrasion, scrapes Amputation Broken bone Bruise Burn (heat) Burn (chemical) Struck on the head Crushing Injury Cut, laceration, puncture Hernia Illness Sprain, strain Repetitive Strain Injury Exposure to Chemicals Radiation (Exposure) Insect / Animal Bite Flying Object – Struck Strike Against Falling Object Stepping on Object Caught in / Between Objects Inhalation of dusts etc Electrical contactForward to SupervisorNameSignature Sign Here DateForward to Manager for filingNameSignature Sign Here DateACCIDENT INVESTIGATIONPlease complete this form if an incident has occurred requiring investigation PART A - INVESTIGATION TEAMInvestingation Team Health & Safety Advisor Supervisor Injured Person OtherOther - Investingation TeamPART C - INCIDENT DETAILSDate and time of IncidentLocation of Incident (Site/Department):Precise Location of Incident:Injury:Incident Type:Person Involved in Incident:Details of Incident:PART C - INVESTIGATION DETAILSInvestigation DetailsFacts Resulting from Investigation:Causes of Incident (Why did it occur?):Corrective Action Taken (What, when, where):PART D - RISK SCORERisk Score - Prior to Corrective Action: Risk Score - After Corrective Action Implemented:Date:Supervisor: Signature Sign Here Forward to Manager Filing, If rehabilitation is required or a lost time injury has resulted continue to complete Page 2 of this formPART E - IDENTIFIED CONTROLSPPE worn at time of incident:Safety instructions received prior to incident:Work Procedure - Title:Available: Yes NoRisk Assessment: Yes NoSafe Work Permit Used: Yes NoInjury recorded in First-aid Register: Yes NoIncident Report Completed: Yes NoPART F - ATTACHED DOCUMENTS Incident Reports (Form 1) Photographs Statements Diagrams Risk assessments Safe Work Permit Job Procedure Other PART H - MANAGEMENT COMMENTSHealth & Safety Advisor Sign Here Supervisor Sign Here Injured Person Sign Here Other Sign Here PART G - INVESTIGATION TEAM SIGNATURESForward to: Supervisor / ManagerSignature: Sign Here DateForward to:Comments:Signature: Sign Here DateSubmit
