HS001

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Hazard and Incident Report Form

The online hazard and incident program in myUNSW is the main method of reporting. This form may be used by persons who do not have access to myUNSW. Refer to HS307 Hazard and Incident Reporting Procedure before completing this form.
Death, serious illness or injury and dangerous incidents must be reported immediately to the Health and Safety Unit by telephone 93851565
PART A - TO BE COMPLETED BY THE PERSON REPORTING
Personal details
Title / Name / Staff/student no.
If you are completing the form on behalf of someone else complete their details below
Title / Name / Staff/student no.
Staff / Yes/No / Student / Yes/No / Contractor/Labour hire / Yes/No / Visitor / Yes/No
Home address
Email / Mobile / Tel
Faculty/Division / School / Unit
Position / Male/Female
Supervisor / UNSW contact person details
Report details
Type of issue: / Hazard / First aid
Incident / Injury / Security
Workplace inspection / Environment
Date of hazard / incident / Time of hazard/injury
Location of hazard / incident / Building / Floor / Room no.
Off-campus address
Hazard / incident category / Air Quality / Animals & insects / Biological exposure / Building damage or defect / Chemical exposure / Electrical / Ergonomic / Fire or explosion / Housekeeping / Manual Handling / Needlestick or sharp / Noise / Plant or equipment / Pressure / Radiation exposure / Repetitive movement or overuse / slip, trip, fall / Temperature / Transport / Environmental / Other
Description of hazard / incident
Description of injury
Did you have any time off work? / Yes/No / Specify dates:
Did your normal work need to be altered due to the injury / Yes/No / Is it still altered?
Did you see a doctor? / Yes/No / Did you get a WorkCover medical cert?
Did you receive first aid? / Yes/No / First aider name:
First aid treatment received:
Have there been costs associated with this injury?
Was there a witness / Yes/No / Witness details
Signature
I approve the release of the information in this form to approved authorizes which may include medical practitioners, legal representatives, employee associations, insurance companies and SafeWork NSW
Signature / Date:
Send Part A to:
  1. Your supervisor
  2. Health and Safety Coordinator for your Faculty
/ Date form forwarded:
PART B – TO BE COMPLETED BY THE SUPERVISOR
This section is to be completed by the supervisor or UNSW contact person as soon as possible in response to receiving Part A. Refer to HS307 Hazard and Incident Reporting Procedure before completing this form.
Death, serious illness or injury and dangerous incidents must be reported immediately to the Health and Safety Unit by telephone 93851565
Risk evaluation
Consequence of this hazard / Severe / Major / Moderate / Minor / Insignificant
Likelihood of hazard / incident to reoccur / Almost certain / Likely / Possible / Unlikely / Rare
Risk rating (refer to Risk Management Procedure for risk rating table) / Low / Medium / High / Very High
Action / Immediate / today / this week / this month
Do you think there could also be a risk to the environment?
Corrective actions
Hierarchy of control / Yes/No / Corrective action / By who? / By when?
  1. Can this hazard be eliminated?
/ Yes/No
  1. Can this Hazard be substituted by something less dangerous?
/ Yes/No
  1. Can you modify tools or equipment, enclose equipment, or put guards in place?
/ Yes/No
  1. Can the hazard risk be reduced by changing workplace procedures, documenting safe work procedures or training?
/ Yes/No
  1. Can you reduce the Hazard risk by using personal protective equipment or clothing?
/ Yes/No
  1. Do you have any other suggestions or comments?
/ Yes/No
A combination of the above measures may be required to minimize the risk, they must be prioritised in order of 1 to 6 to follow the hierarchy of control
Where you have contacted Facilities Management for action, enter the FM job number
Supervisors signature
Name: / Signature: / Date:
Send copies to:
  1. The injured/affected person (named in Part A)
  2. Health and Safety Coordinator for your Faculty/Division
  3. Chairperson of local Health and Safety Consultation Committee or Health and Safety Representative

Supervisors must follow up on the corrective actions identified and ensure they are completed within the timeframe specified on this form.

HS001 Hazard and Incident Report Form

Version 3.3, 29/02/2016