Incident Report Template Essay

Submitted By reachpoojasunil
Words: 1704
Pages: 7

INCIDENT/INJURY REPORT FORM

Please print clearly
Position:
Outcome:







Employee
Near miss




Volunteer
Injury

Contractor
Property damage

1. DETAILS OF PERSON INVOLVED
Name:

Phone: (H)

Address:

(W)

Sex:





Male

Date of birth:
Position:
Experience in the job:

(years/months)

Start time:




Work arrangement:

Casual



Full-time



am

Part-time



pm



Other

2. DETAILS OF INCIDENT
Date:

Time:

Location:
Describe what happened and how:

3. DETAILS OF WITNESSES
Name:

Phone: (H)

Address:

4. DETAILS OF INJURY
Nature of injury (eg burn, cut, sprain)
Cause of injury (eg fall, grabbed by person)
Location on body (eg back, left forearm)
Agency (eg lounge chair, another person, hot water)

5. TREATMENT ADMINISTERED
First Aid given
First Aider name:
Treatment:
Referred to:



Yes



No

(W)

Female

OHS MANAGEMENT CHECKLIST (ANNUAL REVIEW) FORM

Please print clearly

Yes No
OHS policies / plan
OHS policy developed (written)





Policy includes responsibilities of managers and workers





Policies and procedures reviewed regularly





Workers aware of OHS policies and procedures





OHS plan developed





OHS plan reviewed regularly





Responsible officer appointed





OHS committee elected





Health and safety representatives elected





OHS discussed at staff meetings





OHS discussed at contractor meetings





All new employees receive OHS induction training





Workers receive regular ongoing OHS training





Managers/co-ordinators receive OHS training and updates





Records kept of OHS training (aims, attendance, date, presenter)





Pre-service checks of homes conducted





Checks reviewed regularly





Community venues checked pre-use (access etc)





Offices inspected regularly





System in place for reporting hazards
(eg hazard forms)





Hazards reported by workers





Consultation

OHS training

Managing hazards

Comments

OHS MANAGEMENT CHECKLIST (ANNUAL REVIEW) FORM

Yes No
Managing hazards [cont]
Processes in place to address:

• others























Risk assessments carried out on hazards





Hazards / reports followed up and controlled





Controls reviewed for effectiveness





Client needs considered when addressing hazards ❒



OHS considered when purchasing new equipment (eg for office, vehicles)





Form available for reporting incidents and injuries





Workers (including contractors and volunteers) aware of the reporting procedure





Incidents investigated and documented





Procedure in place for claims management





Process in place to manage rehabilitation and return to work following injury





• manual handling
• isolated work
• slips, trips and falls
• staff security
• electrical hazards
• hazardous substances
• infection control
• pet aggression
• bathroom safety

Incident reporting / investigation

Injury management

Comments

INCIDENT/INJURY REPORT FORM

SECTIONS 6-9 MUST BE COMPLETED BY CO-ORDINATOR
6. DID THE INJURED PERSON STOP WORK?



Yes



No

If yes, state date:

Time:

Time lost (days)

Outcome:




Treated by doctor
Returned to normal work




Hospitalised
Alternative duties




Workers compensation claim
Rehabilitation

7. INCIDENT INVESTIGATION (comments to include causal factors - add extra sheets if needed)

8. RISK ASSESSMENT
Likelihood of recurrence:
Severity of outcome:
Level of risk:

9. ACTIONS TO PREVENT RECURRENCE
Action

By whom

10. ACTIONS COMPLETED
Signed (Manager):

Title:
Date:



Feedback to person involved

Date:

11. REVIEW COMMENTS
OHS committee / staff meeting:
Reviewed by Manager (signed):

Date:

Reviewed by HSR (signed):

Date:

By when

Date completed

CLIENT HOME OHS ASSESSMENT FORM
Please print clearly
Client name:

File Number:

Address:

Phone:

Person completing checklist:

Date:

Location: (draw map and attach if needed)

Parking:

Review date:
Location of door to enter:



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