Incident Investigation Form

To be completed by the Supervisor/Manager (All fields mandatory)

Please refer to the Incident Reporting and Investigation Guideline to assist with the completion of this form.

All investigations must be undertaken by the Supervisor/Manager in consultation with the Elected Health and Safety Representative.

Part 1. Incident DetailsAn online incident notification form should have been completed prior to this form.
Name of Person Injured or Involved in the incident/near miss or incident location / Date of Incident: / DD / MM / YYYY

Part 2. Incident DescriptionComplete each section relevant to the incident

Please attachphotographs, timelines and diagrams of where the incident occurred and equipment being used if appropriate.
2.a / General Incident Details
Please provide details of what occurred including what the involved person was doing immediately prior to the incident and any tools or equipment in use:
(please provide attachments if more space is required)
What time did the incident occur? / AM/PM / SPECIFIC LOCATION:
Was the lighting adequate? / Yes / No / Did the incident occur: / On Steps/Stairs
Was the area clean and tidy? / Yes / No / Indoors / On a Footpath / -Ascending
Was Personal Protective Equipment (PPE) required for the task? / Yes / No / Outdoors / On a Walkway / -Descending
If so, was the person correctly wearing the PPE? / Yes / No / Comments:
2.b / Did the incident involve a Slip, Trip or Fall? / Yes / No (if no, proceed to next section)
Were they carrying anything at the time? / Yes / No / TYPE OF SURFACE:
SHOES WORN: / Sneakers / None / Dry / Wet / Torn
Open / Sandals / High Heels / Carpet / Cement / Gravel
Closed / Boots / Steel Capped / Tile / Road / Grass
WAS THE PERSON: / Walking / Running / Sand / Rocks / Damaged
Turning a corner / Jumping / Any other relevant information?
DID THEY FALL ON THEIR: / Front / Side
Hands/Knees / Back
2.c / Did the incident involve a Manual Task? / Yes / No (if no, proceed to next section)
Were the items within easy reach? / Yes / No / DID THE ACTION INVOLVE:
Was ergonomic equipment used? / Yes / No / Bending / Carrying / Kneeling
Was the equipment being used correctly? / Yes / No / Pulling / Reaching / Twisting
Was the task repetitive or forceful? / Yes / No / Catching / Crouching / Lifting
Distance Item Carried: / Item Weight: / Item Height: / Pushing / Sitting / Lowering
Any other relevant information?
2.d / Did the incident involve Equipment or Plant? / Yes / No (if no, proceed to next section)
What was the equipment or plant being used? / Was the appropriate safety equipment being used? / Yes / No
Was the equipment in good condition?
(consider maintenance records) / Yes / No / Were the Standard Operating procedures being followed? / Yes / No
Any other relevant information?
2.e / Did the incident involve Chemicals? / Yes / No (if no, proceed to next section)
Was a Safety Data Sheet available?
(if yes please attach) / Yes / No / Was a Risk Assessment undertaken? if yes please attach) / Yes / No
Any other relevant information?
2.f / Did the incident involve Electricity? / Yes / No (if no, proceed to next section)
Was the equipment tested and tagged in accordance with ECU’s Electrical Safety Policy? / Yes / No / Was there a Work Instruction for the work being undertaken and it so was it being followed? / Yes / No
Were RCDs in use and properly maintained? / Yes / No / Was the injured person encouraged to seek immediate medical advice? / Yes / No
Any other relevant information?
2.g / Other contributing factors to consider / (tick all those that apply)
Environment – workplace/task design / Environmental conditions (e.g. weather, lighting, ventilation, temperature)
Failure to follow work procedures / Inadequate Supervision
Improper use/storage of materials / Inadequate training
Inadequate equipment function / Lack of experience in task/not competent
Inadequate equipment maintenance / Poor/lack of suitable equipment
Inadequate safety procedures / Untidy work area
Inadequate space / Personal factors (e.g. stress, fatigue, pre-existing medical condition)
Other:
2.h / Key cause(s) of the incident
Please outline the key causes of the incident and include any additional comments or observations
(please provide attachments if more space is required)

Part 3. Preventative action to address identified causes

Please refer to the Guidelines for Accident Investigation available from the Human Resources Services Centre intranet site

Where required, has the identified hazard been reported to the Maintenance Call Centre? / Yes / No
What is the Hazard Report Number (QFM Report Number)?
Has the hazard been reported anywhere else?
Please outline the action to be taken to prevent a future occurrence
Consider the hierarchy of controls which outlines the most effective to the least effective method of controls
Risk Control Options / Action to be taken / Person Responsible / Date to be completed
Most effective

Least effective / Elimination
(e.g. remove)
Substitution
(e.g. alternate)
Engineering/
Isolation
(e.g. guarding)
Administration
(e.g.training, standard operating procedures)
Personal Protective Equipment
(e.g. safety glasses, gloves)

Part 4. Sign Off

DD / MM / YYYY
Person Injured / involved:Signature: / Date:
DD / MM / YYYY
Elected H&S Representative:Signature: / Date:
DD / MM / YYYY
Line Manager:Signature: / Date:
DD / MM / YYYY
Dean / Director:Signature: / Date:

Part 5. Record Keeping

Updating the Hazard Risk Register
For more information on how your Faculty or Service Centre Hazard Risk Register can be updated, contact the Chair of your Local Work Health & Safety Committee
Have hazards identified as contributing to this incident been included in the area’s Hazard Risk Register?
If not, please review and add to the register. / Yes / No
Incident Investigation Form Submission
Completed and Signed copy to be provided within 5 working days to:
Line Manager
Elected Safety and Health Representative
Safety and Employment Relations, Human Resources Services Centre (Building 1, Joondalup Campus or )

HPRM Sub Folder: SUB/1147Incident Investigation Form

Version 1.1Uncontrolled when printedApril 2016

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