ACCIDENT/INCIDENT REPORT FORM

ACCIDENT/INCIDENT REPORT FORM

EMPLOYEE TO COMPLETE - ALL QUESTIONS MUST BE ANSWERED

Surname: .............................................Given Name/s….....................................................

Date of Birth: ......................Dept/Ward ...................................Years of Service: ..............

Payroll No.: .........................Classification :........................................................................

______________________________________________________________________
DATE OF OCCURRENCE REPORTED TO SUPERVISOR

Date:.............................Time:........................Date:.................................Time:...................

______________________________________________________________________
Exact location of incident:

.............................................................................................................................................

______________________________________________________________________
Please circle yes or no where applicable.

INJURY Yes No Part of body injured.................................................

Type of injury..................................... Did you require medical attention Yes No

If yes who provided the service? Please circle Emergency Own Doctor First Aid

______________________________________________________________________
Did you cease work? Yes No Date:................................Time:..............................

______________________________________________________________________ DESCRIPTION OF INCIDENT/ACCIDENT

1. What task and/or action was being performed at the time of the incident?

______________________________________________________________________

______________________________________________________________________
TO BE COMPLETED BY EMPLOYEE AND SUPERVISOR/MANAGER

Please circle where applicable

2. Is there an established procedure for this task? Yes No Don't know

3. Was the procedure being followed? Yes No N/A

4. Was appropriate equipment provided? Yes No N/A

5. Was appropriate equipment used correctly? Yes No N/A

If you answered NO to questions 3, 4 or 5 please complete question 6 otherwise go to question 7.

6. Why was the procedure not followed?

_______________________________________________________________________

7. What action could have prevented this occurrence?

_______________________________________________________________________

8. Was training provided for this task? Yes No

9. To your knowledge has there been any other incident/accident of this type before?

Yes No

10. If yes how many and when?.......................................................................................

______________________________________________________________________

ALL INCIDENTS MUST BE INVESTIGATED WITHIN 48 HOURS OF OCCURRENCE BY MANAGERS AND SUPERVISORS

Date of investigation........................Action taken to prevent a recurrence ____________

______________________________________________________________________ This section must be signed by the following:

Employee.............................Witness (if any)...............................OH&S Rep.....................

Supervisor/Nurse Manager..................................Dept Head.....…......................................

WHEN COMPLETED RETURN FORM TO OCCUPATIONAL HEALTH AND SAFETY UNIT