/ Confidential Incident / Injury / Near Miss Report Form
PART 2 - SUPERVISOR / MANAGER INVESTIGATION
(to be completed and sent to UWA safety and health within five working Days)

TO COMPLETE ON SCREEN - tab between fields MAKING ENTRIES BY typing INto the grey highlighted boxes WHICH EXPAND AS REQUIRED

Section A

Injured personS details Reporting person details (if different to injured person)
Last Name: / Title: / Gender: / Last Name: / Title: / Gender:
Other names: / Other names:
Date of Birth: / Staff/Student No: / Date of Birth: / Staff/Student No:
Are you: Staff: Student: Contractor: Visitor: / Are you: Staff: Student: Contractor: Visitor:
Occupation: / Occupation:
Work phone: / Home: / Work phone: / Home:
Mobile: / Email: / Mobile: / Email:
Faculty / Contracting Company: / Faculty / Contracting Company:
School / Centre: / School / Centre:
Home address: / Home address:
State: / Postcode: / State: / Postcode:
Signature: Date: / Signature: Date:
Incident details - for electrical incidents, immediately also notify FM Technical Officer (Electrical) on (08) 6488 2031
or Building Services Electrical Supervisor on (08) 6488 2016
Incident Injury Near miss Illness/disease / Date of occurrence: / Time: (am / pm)
Exact Location:
How did the incident/injury happen (please provide a step by step account):
Witness1: / Witness2:
Phone: / Phone:

Section B

NOTIFIED Safety and Health Representative
Name: / Date Notified: / Time: (am / pm)
Signature: / Contact Phone No:
NOTIFIED Supervisor / Manager
Name: / Date Notified: / Time: (am / pm)
Signature: / Contact Phone No:

Section C

Details of injury, illness or disease
Type of injury or disease (e.g. bruise, cut, sprain): / Part(s) and side of the body affected:
Please specify when were the symptoms first noticed: / Noticed on Date: / Time: (am / pm)
Medical treatment: Hospital Doctor Nurse First Aid None Other:
Person giving treatment: / Treatment Date: / Time: (am / pm)
If a UWA employee, does the injured person intend to lodge a workers’ compensation claim? Yes No Unknown
(if yes, an additional form must be completed)
Will time be lost as a result of the injury? Yes How many hours/days? No
Person who was injured
or involved in incident: / Date of injury / incident:
Section A
Was the accident a Slip, trip or Fall? If YES complete below If NO go to next section
Was there adequate lighting?
Was housekeeping a contributing factor?
Time of day: / Dawn/Dusk / Daylight / Night
Specific Location: / Indoors / Outdoors (covered) / Outdoors (uncovered) / Steps / Stairs / Walkway
*** Please attach a diagram of where the slip / trip / fall occurred, showing exact location, if appropriate ***
Type of surface: / Carpet / Cement / Damaged / Dry / Footpath / Grass
Gravel / Road / Rocks / Sand / Tile / Torn / Wet
Other (explain):
Shoe type worn: / Boots / Closed / High heels / None / Open / Sandals
Other (explain):
Were they: / Jumping / Running / Walking / Turning around a corner
Other (explain):
If Slip / Trip or Fall occurred on stairs, were they? / Descending / Ascending
Did they fall on their? / Back / Front / Side
Where they carrying anything at the time? No / Yes / Details:
Did the incident involve a manual task? If YES complete below If NO go to next section
Were work items within easy reach? / Yes / No / N/A
Was ergonomic equipment available? / Yes / No / N/A
Was the equipment being used correctly? / Yes / No / N/A
Repetitive and/or forceful movements used? / Yes / No / N/A
Weight of the object being moved: / Load height: / Distance carried:
Did the action involve? / Bending / Catching / Carrying / Kneeling / Lifting / Lowering
Pulling / Pushing / Reaching / Sitting / Stooping / Twisting
Other (explain):
Did the incident involve equipment / plant? If YES complete below If NO go to next section
Describe the equipment / plant involved?
Was the equipment in good condition? / Yes / No / Last service date:
Standard Operating procedure followed? / Yes / No / N/A
Was appropriate safety equipment (PPE) used? / Yes / No / N/A
Did the incident involve chemicals? If YES complete below If NO go to next section
Was a Material Safety Data Sheet (MSDS) available? / Yes / No / N/A
Were storage, handling, disposal practices adequate? / Yes / No / N/A
Was Job Safety Analysis (inc. Risk Assessment) done? / Yes / No / Date completed:
*** Please attach the msds, if applicable ***
Tick boxes to indicate if any of the following factors contributed to the incident:
Environment – workplace/task design / Inadequate supervision
Failure to follow work procedures / Inadequate training
Improper use/storage of materials / Personal Protective Equipment inappropriate/not used
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)
Environmental conditions
(e.g. weather, lighting, ventilation, temperature)
Other (explain):
Incident / Injury:
Please provide detail of what injured person was doing prior to the incident and what tools or equipment were being used:
Information relating to competently carrying out the task or activity:
Were they instructed or trained to ensure competence? / Yes / No / How long had they been working on this task?
Were they following a procedure or directly supervised? / Yes / No
Was the task part of the staff member’s normal duties? / Yes / No
If ‘No’ to any of the above questions, please explain why they were carrying out the task:
Investigator’s comments and observations:

Section B

A hierarchy of control should be used to assist with the prevention of future similar injuries. The ‘hierarchy of control’ depicts the most to the least effective methods, as shown in the table below. Please complete all sections.

RECOMMENDATIONS TO PREVENT REOCCURENCE OF THIS HAZARD:
RISK CONTROL OPTIONS / REQUIRED ACTION / BY WHOM / BY WHEN
Elimination (e.g. remove)
Substitution (e.g. alternate)
Engineering (e.g. controls/guards)
Administration (e.g. standard operating procedures, training)
Personal Protective Equipment (e.g. safety glasses, helmets, gloves)
Manager/Supervisor name: / Signature: / Phone: / Date: / Mailbag:
Head of School/School Manager name: / Signature: / Phone: / Date: / Mailbag:
Safety & Health Representative name: / Signature: / Phone: / Date: / Mailbag:
Safety and Health use only - Recommendations
Is further investigation required? / Yes No
Comments:
Safety and Health Advisor name: / Signature: / Date:
Confidential Incident / Injury / Near Miss Report - Supervisor / Manager Investigation / Published: / March 2014 / Version 1.6
Authorised by UWA Safety and Health / Review: / March 2019 / Page 3 of 3
This document is uncontrolled when printed - the current version is on the Safety, Health and Wellbeing website