HOW DO I USE THIS FORM? USER GUIDE on last page.
PRINT VERSION ONLY
OFFLINE HEALTH AND SAFETY INCIDENT REPORT FORM
(V9AMyHR WH&SAUTOMATEDForm 29.7.2011)
This form should be used in accordance with DET policy:
HLS-PR-005: Health and Safety Incident Recording, Notification and Management
Privacy: The Department of Education and Training (Qld) is collecting personal health and safety incident information on this form in accordance with the Workplace Health and Safety Act 1995 (Qld), Workplace Health and Safety Regulation 2008, Electrical Safety Act 2002 (Qld), and/or Electrical Safety Regulation 2002. The information collected may be disclosed to third parties, including the Government Superannuation Office, Australian Tax Office, Workplace Health and Safety Queensland, Electrical Safety Office (Qld), WorkCover Queensland, Industrial Organisations, or other entities in accordance with, or where requested by law or industrial instrument. The information collected on this form will be manually entered into the MyHR Workplace Health and Safety Solution for review by a supervisor. A copy of the original form will be stored securely as an attachment to the electronic version of the incident record.
*DenotesMandatory Fields that mustbe completed.
* Date reported: Reported time (24 hour HH:mm):
*Reported by : – (NOTE: at least one ‘reported by’ field must be populated)
Staff name:
Student name:
Other person name:
Type of other person: Client Contractor Parent Visitor Volunteer Other:
Other person address (if known):
Suburb: State: Postcode:
Other person contact number: (M) (W)(H)
Other person employer:
Reported to:
* Date of incident: Time incident occurred: (24 hour hh:mm)
If the Incident occurred at a Departmental location, select this location as the Departmental Incident Location below.
If the Incident occurred at a Non-Departmental location select your Base Location and complete the Non-Departmental Incident Location field.
*Departmental Incident Location or Base location:
Non-Departmental Incident Location:
*Actual incident address1:
(Actual address of DET or non-DET incident location)
Actual incident address2:
*Suburb: *State (eg. QLD): Post Code:
*Summary/Description of incident:
Immediate Action Taken:(eg: administered first aid, ambulance called, doctor/ out patients or hospitalisation)
Was a hazard identified as a result of the incident? Yes(detail below) No
(New hazards can be enteredinto MyHR WHS Solution)
Hazard Details:
*Supervising officer:
(The Supervising officer is a DET employee assigned to review the details of this incident eg: Principal, Deputy, Team leader or Director)
(In the MyHR WHS Solution the supervising officer can review the incident details)
Elected Workplace Health & Safety Representative (if applicable):
Did an evacuation occur? Yes No Did a lockdown occur? Yes No
Location/s involved:
INSTRUCTIONS: Select one or more Incident Types – however if the incident is considered a ‘Near Miss’no other selection can be made. If ‘Property/Plant/Equipment’or‘Fire’ or‘Environmental’or ‘Electrical’ are selected as the incident type, the question ‘Was this a Dangerous Event as defined under legislation’ will appear and must be answered either ‘Yes’ or ‘No’.
Incident TypesInjury/Illness
Electrical
Security Threat / Motor Vehicle
Fire
Environmental / Property/Plant/Equipment
Near Miss
Did this incident occur during a journey to or from work or during an ordinary recess break at work? YES NO
Was this a Dangerous Event as defined under legislation? YES NO
(The MyHR WHS Solution provides a link to afact sheet explaining Dangerous Events and provides examples)
()
ATTENTION! : If you selected incident type = ElectricalOR indicated ‘YES’ this record is a dangerous event, the incident record is now considered a 'NOTIFIABLE EVENT' and by law must be reported to - Workplace Health and Safety Queensland (WHSQ) - within 24 hours of the incident occurring.
STEPS TO FOLLOW TO RECORD AND REPORT A NOTIFIABLE INCIDENT:
1. Complete the Offline Health and Safety Incident Report Form and any incident sub-forms selected.
2. Print the form. You should have 2 pages for the incident record plus any incident type sub-forms selected.
3. Fax all pages to Workplace Health and Safety Queensland on (07) 3247-0297 within 24 hours of the incident date.
4. Once access to the MyHR WH&S Solution has been restored, enter the incident details into the MyHR WH&S Solution. The incident will be reviewed on-linevia the MyHR WH&S incident management process.
5. Scan the completed offline report form and upload to the corresponding online MyHR WH&S incident record in the 'attachments' field.
Refer to HLS-PR-005: Health and Safety Incident Recording, Notification and Management to determine ‘Notifiable Events’
*Denotes Mandatory Fields that must be completed.
Provide a detailed description of the injury or illness (ie: fractured right ankle following fall on school oval)
*TheInjured Person’s Details: (select one box only)
DET Staff Member Student Other person eg: volunteer, parent or contractor
Surname: Given name/s:
(NOTE: If more than one person was injured/ill in the same incident, please complete an additional injury/illness details page for each person involved. Tick YES for additional person at the end of this form and a new sub-form will appear.)
BASE LOCATION of injured staff member or injured student or other person:
DET Staff Role at time of injury/illness (ie: teacher, admin officer etc):
Other person address:
Other person Suburb: Post Code: Other person Phone Number:
Type of other person (select one): Client Contractor Parent Visitor Volunteer TAFE Volunteer Tutor
Other:
* Injury/Illness Classification – select one of the following(GUIDELINES FOR INJURY/ILLNESS CLASSIFICATION)
Serious Bodily Injury – Fatality (Class A)
Serious Bodily Injury – Non Fatality (Class A) / Work Caused Injury (Class A)
PsychologicalIllness ( Class P) / Bodily Injury (Class B)
WorkCover Journey/Recess Claim (Class C)
Minor Injury or Incident (Class C)
*Bodily Location– select one / *Nature of Injury / Illness- select one
Face
Head
Eyes
Ears
Nose
Tooth/teeth
Neck
Arms
Elbows
Shoulders / Hands
Wrists
Back
Mouth
Chest
Fingers
Abdomen/Stomach
Hips
Legs
Groin Area / Knees
Foot/Feet
Toes
Ankles
Skin
Respiratory System
Internal Organs
Spine
Psychological Condition
Other / Ache/Pain
Cut/Laceration
Amputation
Bite/Sting
Bruising/Crushing
Dislocation
Sprain/Strain
Burn/Scald
Fracture / Infection/Disease
Hearing Loss/Deafness
Psychological Stress
Allergy
Skin Irritation/Dermatitis
Heat/Cold Stress
Poisoning
Respiratory
Puncture/Needlestick / Weld Flash
Eye Disorder
Foreign Body
Head Injury
Internal Injury
Heart or Circulatory Condition
Other
Did the injured person have more than one injury?
Yes – if selected please indicate second injury on next page.No
ATTENTION ! : If you selected an injury/illness classification = A, the incident is now considered a 'NOTIFIABLE EVENT' and by law must be reported to - Workplace Health and Safety Queensland - within 24 hours of the incident occurring.
STEPS TO FOLLOW for a NOTIFIABLE INCIDENT:
1. Complete the Offline Health and Safety Incident Report Form and any incident sub-forms selected.
2. Print the form. You should have 2 pages for incident record plus any incident type sub-forms selected.
3. Fax all pages to Workplace Health and Safety Queensland on (07) 3247-0297 within 24 hours of the incident date.
4. Once access to the MyHR WH&S Solution has been restored, enter the details of this incident into the solution. The incident will be reviewed through the on-line viathe MyHR WH&S incident management process.
5. Scan the completed offline report form and upload to the corresponding on-line MyHR WH&S incident record in the 'attachments' field.
Refer to policy HLS-PR-005: Health and Safety Incident Recording, Notification and Management to determine ‘Notifiable Events’
*Bodily Location– select one / *Nature of Injury / Illness– select oneFace
Head
Eyes
Ears
Nose
Tooth/teeth
Neck
Arms
Elbows
Shoulders / Hands
Wrists
Back
Mouth
Chest
Fingers
Abdomen/Stomach
Hips
Legs
Groin Area / Knees
Foot/Feet
Toes
Ankles
Skin
Respiratory System
Internal Organs
Spine
Psychological Condition
Other / Ache/Pain
Cut/Laceration
Amputation
Bite/Sting
Bruising/Crushing
Dislocation
Sprain/Strain
Burn/Scald
Fracture / Infection/Disease
Hearing Loss/Deafness
Psychological Stress
Allergy
Skin Irritation/Dermatitis
Heat/Cold Stress
Poisoning
Respiratory
Puncture / Needlestick / Weld Flash
Eye Disorder
Foreign Body
Head Injury
Internal Injury
Heart or Circulatory Condition
Other
*Cause of Injury/Illness– select one of the following
Slip, Trip or Fall
Contact with, or striking against object
Vibration
Struck by falling or moving object
Noise
Explosion or implosion (pressure variation) / Repetitive movement
Muscular effort – single event
Electricity
Thermal (heat/cold)
Radiation
Chemical or substance / Animal or insect
Biological
Psychological
Vehicle
Other
* Contributing Factor/Agency – select one of the following
Machinery and fixed plant
Mobile plant/machinery
Vehicle (Government)
Vehicle (Private)
Powered equipment, tools and appliances
Non-powered tools
Non-powered equipment (eg: playground) / Chemicals
Foreign Objects (eg: projectiles, splinters)
Outdoor environment
Indoor environment
Animals
Human agencies
Biological agent / Needlestick
Fire/explosion
Electricity
Radiation/Arc Flash
Stress/Trauma
Temperature
Other
* Activity – select one of the following
Admin general
Chemical use
Computer work
Curriculum prac
Curriculum theory
Playground duty
Equipment usage / First aid
Lifting/Manual handling
Movement around the worksite
Grounds Care
Play (supervised/unsupervised)
Restraining a student / Sport
Travel to/from workplace
Excursions/Field trip
Work General
Other
* Initial Response – select one of the following
Nil – returned to work or class
First Aid / Ambulance
Doctor/Out Patient / Hospitalisation
Name of hospital (if known):
If First Aid was provided, please detail what was provided and by whom:
Do you want to lodge a WorkCover Claim for this incident? YES NO
NOTE: In the event the MyHR WHS Solution is not available, please complete an onlineclaim form available at –
Was another person injured as a result of this incident?
Yes – if selected another injury/illness page will appear need to be printed No
*Denotes Mandatory Fields that must be completed.
*Injured Person’s Details:
(if more than one person was injured/ill in the same incident, please complete an additional injury/illness details for each person)
Staff Member Student Other person eg: volunteer
Given name: Surname:
Payroll number (DET staff only):
DET staff role at time of injury/illness:
Other person address:
Other person Suburb: Post Code: Other person Phone Number:
Type of other person: Client Contractor Parent Visitor Volunteer TAFE Volunteer Tutor
Other:
*Detailed Description of injury/illness (ie: fractured right ankle)
* Injury/Illness Classification(GUIDELINES FOR INJURY/ILLNESS CLASSIFICATION)
Serious Bodily Injury - Fatality (Class A)
Serious Bodily Injury – Non Fatality (Class A) / Work Caused Injury (Class A)
Bodily Injury (Class B) / Minor Injury or Incident (Class C)
Psychological Injury (Class P)
*Bodily Location (1) / *Nature of Injury / Illness (1)
Face
Head
Eyes
Ears
Nose
Tooth/teeth
Neck
Arms
Elbows
Shoulders / Hands
Wrists
Back
Mouth
Chest
Fingers
Abdomen/Stomach
Hips
Legs
Groin Area / Knees
Foot/Feet
Toes
Ankles
Skin
Respiratory System
Internal Organs
Spine
Psychological Condition
Other / Ache/Pain
Cut/Laceration
Amputation
Bite/Sting
Bruising/Crushing
Dislocation
Sprain/Strain
Burn/Scald
Fracture / Infection/Disease
Hearing Loss/Deafness
Psychological Stress
Allergy
Skin Irritation/Dermatitis
Heat/Cold Stress
Poisoning
Respiratory
Puncture / Needlestick / Weld Flash
Eye Disorder
Foreign Body
Head Injury
Internal Injury
Heart or Circulatory Condition
Other
Was another Bodily Location injured?YesNo
ATTENTION ! : You have selected a specific incident type, or nominated that this record is a dangerous event, or selected an injury/illness classification = A. This means this incident record is considered a 'NOTIFIABLE EVENT' and by law must be reported to - Workplace Health and Safety Queensland - within 24 hours of the incident occurring.
STEPS TO FOLLOW for a NOTIFIABLE INCIDENT:
1. Complete the Offline Health and Safety Incident Report Form and any incident sub-forms selected.
2. Print the form. You should have 2 pages for the incident record plus any sub-forms selected.
3. Fax all pages to Workplace Health and Safety Queensland on (07) 3247-0297 within 24 hours of the incident date.
4. Once access to the MyHR WH&S Solution has been restored, enter the details of this incident into the solution. The incident will be reviewed through the on-line MyHR WH&S process.
5. Scan the completed offline report form and upload to the corresponding MyHR WH&S incident record in the 'attachments' field.
Refer to HLS-PR-005: Health and Safety Incident Recording, Notification and Management to determine ‘Notifiable Events’
*Bodily Location (2) / *Nature of Injury / Illness (2)Face
Head
Eyes
Ears
Nose
Tooth/teeth
Neck
Arms
Elbows
Shoulders / Hands
Wrists
Back
Mouth
Chest
Fingers
Abdomen/Stomach
Hips
Legs
Groin Area / Knees
Foot/Feet
Toes
Ankles
Skin
Respiratory System
Internal Organs
Spine
Psychological Condition
Other / Ache/Pain
Cut/Laceration
Amputation
Bite/Sting
Bruising/Crushing
Dislocation
Sprain/Strain
Burn/Scald
Fracture / Infection/Disease
Hearing Loss/Deafness
Psychological Stress
Allergy
Skin Irritation/Dermatitis
Heat/Cold Stress
Poisoning
Respiratory
Puncture / Needlestick / Weld Flash
Eye Disorder
Foreign Body
Head Injury
Internal Injury
Heart or Circulatory Condition
Other
* Cause of Injury/Illness
Slip, Trip or Fall
Contact with, or striking against object
Vibration
Struck by falling or moving object
Noise
Explosion or implosion (pressure variation) / Repetitive movement
Muscular effort – single event
Electricity
Thermal (heat/cold)
Radiation
Chemical or substance / Animal or insect
Biological
Psychological
Vehicle
Other
* Contributing Factor/Agency
Machinery and fixed plant
Mobile plant/machinery
Vehicle (Government)
Vehicle (Private)
Powered equipment, tools and appliances
Non-powered tools
Non-powered equipment (eg: playground) / Chemicals
Foreign Objects (eg: projectiles, splinters)
Outdoor environment
Indoor environment
Animals
Human agencies
Biological agent / Needlestick
Fire/explosion
Electricity
Radiation/Arc Flash
Stress/Trauma
Temperature
Other
* Activity
Admin general
Chemical use
Computer work
Curriculum prac
Curriculum theory
Playground duty
Equipment usage / First aid
Lifting/Manual handling
Movement around the worksite
Grounds Care
Play (supervised/unsupervised)
Restraining a student / Sport
Travel to/from workplace
Excursions/Field trip
Work General
Other
* Initial Response
Nil – returned to work/class
First Aid / Ambulance
Doctor/Out Patient / Hospitalisation
Name of hospital (if known):
If First Aid was provided, please detail what was provided and by whom:
Do you want to lodge a WorkCover Claim? YES NO
(The MyHR WHS Solution will enable completion and lodgement of WorkCover claims electronically)
NOTE: In the event the MyHR WHS Solution is not available, please complete an online claim form at –
Was another Person Injured?YesNo
*Denotes Mandatory Fields that must be completed.
*Injured Person’s Details:
(if more than one person was injured/ill in the same incident, please complete an additional injury/illness details for each person)
Staff Member Student Other person eg: volunteer
Given name: Surname:
Payroll number (DET staff only):
DET staff role at time of injury/illness:
Other person address:
Other person Suburb: Post Code: Other person Phone Number:
Type of other person: Client Contractor Parent Visitor Volunteer TAFE Volunteer Tutor
Other:
*Detailed Description of injury/illness (ie: fractured right ankle)
* Injury/Illness Classification(GUIDELINES FOR INJURY/ILLNESS CLASSIFICATION)
Serious Bodily Injury - Fatality (Class A)
Serious Bodily Injury – Non Fatality (Class A) / Work Caused Injury (Class A)
Bodily Injury (Class B) / Minor Injury or Incident (Class C)
Psychological Injury (Class P)
*Bodily Location (1) / *Nature of Injury / Illness (1)
Face
Head
Eyes
Ears
Nose
Tooth/teeth
Neck
Arms
Elbows
Shoulders / Hands
Wrists
Back
Mouth
Chest
Fingers
Abdomen/Stomach
Hips
Legs
Groin Area / Knees
Foot/Feet
Toes
Ankles
Skin
Respiratory System
Internal Organs
Spine
Psychological Condition
Other / Ache/Pain
Cut/Laceration
Amputation
Bite/Sting
Bruising/Crushing
Dislocation
Sprain/Strain
Burn/Scald
Fracture / Infection/Disease
Hearing Loss/Deafness
Psychological Stress
Allergy
Skin Irritation/Dermatitis
Heat/Cold Stress
Poisoning
Respiratory
Puncture / Needlestick / Weld Flash
Eye Disorder
Foreign Body
Head Injury
Internal Injury
Heart or Circulatory Condition
Other
Was another Bodily Location injured?YesNo
ATTENTION ! : You have selected a specific incident type, or nominated that this record is a dangerous event, or selected an injury/illness classification = A. This means this incident record is considered a 'NOTIFIABLE EVENT' and by law must be reported to - Workplace Health and Safety Queensland - within 24 hours of the incident occurring.
STEPS TO FOLLOW for a NOTIFIABLE INCIDENT:
1. Complete the Offline Health and Safety Incident Report Form and any incident sub-forms selected.
2. Print the form. You should have 2 pages for the incident record plus any sub-forms selected.
3. Fax all pages to Workplace Health and Safety Queensland on (07) 3247-0297 within 24 hours of the incident date.
4. Once access to the MyHR WH&S Solution has been restored, enter the details of this incident into the solution. The incident will be reviewed through the on-line MyHR WH&S process.