DOC

ACCIDENT INCIDENT NEAR MISS REPORT FORM

By Cheryl Coleman,2014-06-26 19:30
6 views 0
ACCIDENT INCIDENT NEAR MISS REPORT FORM ...

     Catholic Safety Health & Welfare SA

    ACCIDENT / INCIDENT / NEAR MISS REPORT FORM

    INSTRUCTIONS

    OHS&W Regulations 1995 Pt 6 Div. 6.6 This form is to be used to report all incidents and accidents including

    Notification of Certain Occurrences near misses.

    Any injury resulting in death or requiring treatment as an in-patient in a All occurrences must be reported to your immediate

    hospital, acute symptoms associated with exposure to a substance. supervisor/manager as soon as practicable and within 24hrs.

    Dangerous occurrences Electrical short circuit, malfunction or

    explosion, uncontrolled explosion, fire or escape of gas, hazardous Page 1 To be completed by person reporting the incident.

    substance or steam.

     Part A To be completed by the injured person or another

    Reason for notification: ...................................................................... person on behalf of the injured person.

     .......................................................................................................... Part B To be completed by the Manager/Supervisor in consultation with ALL affected parties. Have you contacted your OHS Consultant? ? Yes ? No NOTE: CSH&W after hours ph 0438396062 Part C Completed in the case of a sustained injury by either the person involved and/or the person conducting the Has SafeWork SA been notified within 24 hrs? ? Yes ? No investigation. SafeWork SA contact No: 1800 777 209 If a claim is to be lodged please forward a copy of the full report to CCI

    within 3 working days from the date of the injury. Ref no._______________

    1 C:\convert\temp\61481187.doc

    Review Date: January 2010

     Catholic Safety Health & Welfare SA

    WORKSITE: ...................................................................................................................................................................................................... ADDRESS ......................................................................................................................................................................................................... SITE CONTACT PERSON: ................................................................................................................................................................................ PHONE: ........................................................................................... EMAIL: ...................................................................................................

    SUMMARY OF INCIDENT

    Incident resulted in: Position of person involved/injured:

    Employee ? Self-employed ? No Injury/Near Miss ? Injury (lost time) ?

    ? Visitor ? Contractor ? Damage to property ? Exacerbation of previous Injury ? Volunteer ? Other __________________________ ? Injury (No lost time)

     AM/PM Date of Incident Time of Incident

     AM/PM Date Reported Time Reported

    Reported to

    Describe briefly what happened:

    2 C:\convert\temp\61481187.doc

    Review Date: January 2010

     Catholic Safety Health & Welfare SA

     PART A

    NAME OF PERSON INJURED/INVOLVED:

     _________________________________________________________________________________________________________________ Surname Given Name/s

    Age Group ? ? ? ? ? ? ? Gender (M / F) ? ?

     <20 20-29 30-39 40-49 50-59 60-79 80+ M F

Occupation/Job Title_____________________________________________ Contact Phone No. (Wk)_________________ (Hm) _______________________ (Mob) _________________________

    Home Address ____________________________________________________________________________________________________

    NAME OF PERSON SUBMITTING DETAILS: (if differenet from above)

     _________________________________________________________________________________________________________________ Surname Given Name/s

    Contact Phone No.(Wk) _________________ (Hm) _______________ (Mob) ________________

    NAME OF PERSON/s WHO WITNESSED INCIDENT OR FIRST CAME TO SCENE:

     _________________________________________________________________________________________________________________ Surname Given Name/s

    Contact Phone No. (Wk)_________________ (Hm) _______________ (Mob)________________

     _________________________________________________________________________________________________________________ Surname Given Name/s

    Contact Phone No. (Wk)_________________ (Hm) _______________ (Mob) _______________

     PART B

    INCIDENT/ INVESTIGATION DETAILS: add additional pages and photographs as required

    Date on which investigation commenced: / /

    EXACT LOCATION OF INCIDENT: eg. Particular building/room, while in transit (vehicle etc)

     _________________________________________________________________________________________________________________

     _________________________________________________________________________________________________________________

    EXPLAIN THE WORK/ACTIVITY BEING UNDERTAKEN AT THE TIME OF INCIDENT: Identify any plant/substance/equipment involved

     _________________________________________________________________________________________________________________

     _________________________________________________________________________________________________________________

    WHAT HAPPENED? Please include a description of events:

     _________________________________________________________________________________________________________________

     _________________________________________________________________________________________________________________

     _________________________________________________________________________________________________________________

     _________________________________________________________________________________________________________________

     _________________________________________________________________________________________________________________

     _________________________________________________________________________________________________________________

     _________________________________________________________________________________________________________________

    3 C:\convert\temp\61481187.doc

    Review Date: January 2010

     Catholic Safety Health & Welfare SA

    WHAT FACTORS CONTRIBUTED TO THE INCIDENT?

    People: (eg culture, language, fatigue?) ________________________________________________________________________________

     _________________________________________________________________________________________________________________

    Total hours worked when incident occurred ____________hrs

    Environment: (eg lighting, temperature, wind?) __________________________________________________________________________

     _________________________________________________________________________________________________________________

     _________________________________________________________________________________________________________________

    Plant/Equipment: (eg guarding, maintenance, type of plant/equipment?) _____________________________________________________

     _________________________________________________________________________________________________________________

     _________________________________________________________________________________________________________________

    Materials: (eg suitable for task, clothing, footwear, personal protective equipment, materials used?) _______________________________

     _________________________________________________________________________________________________________________

     _________________________________________________________________________________________________________________

    Procedure/Job/Task: (eg appropriate procedure, task organisation, training, SOP’s, supervision?) ________________________________

     _________________________________________________________________________________________________________________

     _________________________________________________________________________________________________________________

    LIST ACTIONS TO PREVENT REOCCURRENCE Manager/Supervisor should complete in consultation with the H&S Rep where appointed and those involved.

     Immediate Action Taken ___________________________________________________________________________________________

     _________________________________________________________________________________________________________________

     _________________________________________________________________________________________________________________

    Interim Controls: (Short Term)

     _________________________________________________________________________________________________________________

     _________________________________________________________________________________________________________________

    Proposed Permanent Controls

     _________________________________________________________________________________________________________________

     _________________________________________________________________________________________________________________

    Action plan/Hazard Register updated ? Yes ? No Ref No_______________ Risk Assessment Ref No______________

    USE HIERARCHY OF CONTROLS in descending order:

     1 ELIMINATION Can you eliminate the hazard altogether

     2 SUBSTITUTION Can you substitute less hazardous equipment, substances or agents 3 ENGINEERING Would the hazard be reduced by ventilation, barriers or isolation 4 ADMINISTRATION Is training, policy or safe working procedures required 5 PERSONAL PROTECTIVE EQUIPMENT What personal protective equipment (PPE) would be appropriate

    Has

    feedback been provided to person/s involved in the incident: Yes Date: / / No SIGN OFF

    Name: ___________________________________ Date: / / Ph: _________________________________

    Signed: _______________________________________________

    Comments: Name of person Investigating incident: _____________________

     Signature: _______________________ Date: / /

    Comments: Name of Health and Safety Representative:_________________

     Signature: _______________________ Date: / /

    C:\convert\temp\61481187.doc Review Date: January 2010 4

     Catholic Safety Health & Welfare SA

    PART C

    Has a Workers Compensation Form been lodged with your employer? Yes No NB Please ensure that your claim for compensation form is lodged with an accompanying Prescribed Medical Certificate from your certifying medical practitioner.

     Asbestosis, Mesothelioma, Silicosis Injuries to nerves & spinal cord Asthma including bronchitis Internal injury of chest, abdomen and pelvis Burns and scalds Intestinal infectious and parasitic diseases Contact dermatitis Intercranial injury, (eg. concussion, etc) Contusion with skin and crushing injury, excluding fracture Legionnaires disease Malignant Melanoma Damage to artificial aids Mental Disorders Deafness Multiple injuries Disease Circulatory system (incl heart disease, hypertension, etc) Open Wound (eg. cuts, laceration, etc) Disease Brain, spinal cord and peripheral nervous system Other and unspecified injuries Disease Skin (eg. contact dermatitis, malignant melanoma, etc) Other and unspecified diseases Dislocation Poisoning / toxic effects Disease Eye (incl conjunctiva and cornea) Respiratory condition due to substance Disorder of the nerve roots, plexuses and single nerves Sexually transmitted disease Disorder of the musculoskeletal system (inch joints, spine, disks, Sprains & Strains of joints & muscles soft tissue, etc) Superficial injury (egg. Cuts and lacerations) Effects of weather, exposure, pressure (includes ‘bends’) Traumatic amputation (including loss of eyeball) Foreign body (in eye, respiratory or digestive system, etc) Ulcers & gastritis Fracture Varicose Veins Heart Disease Viral Disease Hernia Viral Hepatitis Hepatitis or HIV (AIDS)

     Systemic Locations LEFT/RIGHT LEFT/RIGHT Abdomen Large Intestine Circulatory System Ankle Leg/lower limb Digestive System Back Liver Nervous System Bladder Low Back Brain Lung Breast/Larynx, Oesophagus Mouth Chest Neck Psychological System Ear Nose Respiratory System Elbow Other internal organs Eye/Eyeball/Eyebrow Pancreas Face Pelvis Multiple Locations Fingers Ribs Eyes & Ears Foot Shoulder Foot and toes Forearm Small Intestine Hand, Fingers and Thumb Gallbladder Spleen Head & Neck Genital organs Stomach Neck and shoulders Groin Trunk Upper and lower Neck & Spine Hand limbs Neck and trunk Head/Skull Upper arm Heart Upper Back Hip Upper leg Other specified multiple locations Kidney Upper limb Knee Toes Wrist

     Being assaulted by a person Harassment Being bitten by animal Hitting moving objects Being hit by person accidentally Hitting stationary objects Being hit by an animal Insect, spider bites / stings, etc Being hit by falling objects Long-term contact with a chemical or substance Being hit by moving objects (can inch cutting yourself, etc) Long-term exposure to sounds Biological factors (including infectious disease) Muscular stress - no specific incident (no objects being handled) Contact with cold objects Muscular stress - lifting, carrying, pushing, pulling, lowering Contact with hot objects Muscular stress bending, twisting, reaching Contact with electricity Muscular stress - Repetitive movement Exposure to blood, body fluid, needle stick / sharps injury Mental Stress factors Exposure to ionising radiation (egg. x-ray, etc) Rubbing & chafing Exposure to non-ionising radiation (egg. sunburn) Single contact with a chemical or substance Exposure to occupational violence Slide or cave-in Exposure to traumatic event Suicide or attempted suicide Exposure to environmental heat/cold Trapped between stationary & moving objects Exposure to mechanical vibration Trapped by moving machinery Exposure to single, sudden sound Unspecified cause / mechanism of injury Falls from a height Vehicle Accident Fall on the same level (egg. slip or trip) Work pressure Workplace harassment or bullying

    C:\convert\temp\61481187.doc Review Date: January 2010 5

Catholic Safety Health & Welfare SA

C:\convert\temp\61481187.doc Review Date: January 2010 6

Report this document

For any questions or suggestions please email
cust-service@docsford.com