Catholic Safety Health & Welfare SA
ACCIDENT / INCIDENT / NEAR MISS REPORT FORM
INSTRUCTIONS NOTIFICATION OF CERTAIN WORK RELATED
INJURIES AND DANGEROUS OCCURRENCES
This form is to be used to report all incidents and accidents including OHS&W Regulations 1995 Pt 6 Div. 6.6
near misses. Notification of Certain Occurrences
All occurrences must be reported to your immediate Any injury resulting in death or requiring treatment as an in-patient in a
supervisor/manager as soon as practicable and within 24hrs. hospital, acute symptoms associated with exposure to a substance.
Dangerous occurrences – Electrical short circuit, malfunction or
Page 1 – To be completed by person reporting the incident. explosion, uncontrolled explosion, fire or escape of gas, hazardous
substance or steam.
Part A – To be completed by the injured person or another
person on behalf of the injured person. Reason for notification: ..........................................................................
................................................................................................................
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._______________
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WORKSITE: .................................................................................................................................................................................................................
ADDRESS ....................................................................................................................................................................................................................
SITE CONTACT PERSON: ..........................................................................................................................................................................................
PHONE: ................................................................................................ EMAIL: .........................................................................................................
SUMMARY OF INCIDENT
Incident resulted in: Position of person involved/injured:
No Injury/Near Miss Injury (lost time) Employee Self-employed
Damage to property Exacerbation of previous Injury Visitor Contractor
Volunteer Other __________________________
Injury (No lost time)
Date of Incident Time of Incident AM/PM
Date Reported Time Reported AM/PM
Reported to
Describe briefly what happened:
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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:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
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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
SUPERVISOR / MANAGER – I confirm the details of the incident reported and agree with the recommendations made.
Name: ___________________________________ Date: / / Ph: _________________________________
Signed: _______________________________________________
Name of person Investigating incident: _____________________ Comments:
Signature: _______________________ Date: / /
Name of Health and Safety Representative:_________________ Comments:
Signature: _______________________ Date: / /
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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.
NATURE OF INJURY/ DISEASE / DISORDER
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)
BODILY LOCATION OF INJURY (Please tick box for principle body location of injury)
LEFT/RIGHT LEFT/RIGHT Systemic Locations
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
CAUSE / MECHANISM OF INCIDENT (Please tick box for principle mechanism of injury)
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
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