Incident report form by R27zzR

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									INCIDENT REPORT FORM
This form must be completed for an incident involving injury/illness, property/environmental
damage, motor vehicle accident, or “near misses”. Incidents involving actual or potential
significant injury/illness must be reported immediately to the Institute OHS Coordinator, on Ph:
5833 2734 or Fax: 5833 2771 and if an animal is involved a copy must be faxed to the Animal
Ethics Committee on 5753 6380.

Is this a minor incident or report only?       eg, First aid only with no further action required     Yes             No           If yes, complete this page only (Part A)

PART A - INCIDENT NOTIFICATION
 1. DETAILS OF INVOLVED PERSON
 Please indicate by ticking/checking the appropriate box, whether you are:
          Staff Member                 Student                       Visitor                         Other, please specify

 FAMILY NAME                                                                         FIRST NAME

 DATE OF BIRTH                /   /                                                   RESIDENTIAL
                                                                                       ADDRESS &
 GENDER                       Male             Female                                  POSTCODE

 DEPT/DIVISION                                                                 CONTACT PHONE No

 CAMPUS                                                                               OCCUPATION

 DETAILS OF INCIDENT                    Please indicate by ticking/checking the appropriate box, the type of incident:
    Personal Injury/Illness           Property damage               Motor Vehicle                   Environmental Damage                   Animal Ethics Issue                Near Miss

 Describe the incident, ie, what happened to cause the incident, injury or illness?                              (if necessary use back of form as well)




 Please provide details of damage to person/property/environment:                             For personal injury/illness, describe the part of the body injured. eg, fracture to right arm.




 Date & Time Incident Occurred                       /          /                                     Date & Time Reported                          /          /
 Where did the incident occur? (Include Building & Room Number where applicable)

 Who was the Incident reported to?

 Name of Witness (If applicable)                                                                          Contact Phone No

 2. DETAILS OF ACTIONS FOLLOWING INCIDENT
 Did you receive First Aid?              Yes             No                                                            Name of First Aider
 Did you stop work/study?                Yes             No                                  If yes, what date & time did you stop?                        /       /
 Did you go to a Doctor?                 Yes             No             Not yet
 Did you go to Hospital?                 Yes             No
 INVOLVED/INJURED PERSON:                        Signature:                                                                                             Date:

 STAFF/STUDENT SUPERVISOR:                       Name:

                                                 Signature:                                                                                             Date:

       FAX THIS PAGE TO ORGANISATIONAL DEVELOPMENT WITHIN 24 HOURS OF INCIDENT, FAX: 5833 2771
 What happens next?
           Make sure you have reported this incident to your supervisor. You and your supervisor need to identify any steps that are immediately
            required to protect the health & safety of all persons, and take these steps where appropriate. (Such as lock out/tag out).
           Page 2 of this Form (Part B) is to be completed for all Major Incidents (Reportable to WorkSafe) or accidents requiring a doctor or a
            hospital visit. This section is to be completed by the staff/student supervisor and forwarded to OD within 3 days of the Incident Report
            Form (Section A).
           Part B of the Incident Report Form looks at the actions required to prevent similar incidents from occurring.
 FOH-01 (FOH001_Online)                                                                                                                                Issued: 10/09/2010
                                                                                                                                             (Public Web Site) Page 1 of 3
PART B – INCIDENT FOLLOW UP
This is to be filled out for all Major Incidents (Reportable to WorkSafe) or accidents requiring a doctor or a hospital visit.
Follow-up after an incident is to be completed by the relevant supervisor, with the involvement of the Health & Safety
Representative and the person involved in the incident, as appropriate.

INVOLVED PERSON’S NAME:                                                                                        DATE OF INCIDENT:              /    /

3. INCIDENT RESPONSE

4.1 Please describe the immediate response to the incident
For example, were emergency procedures activated, was the area isolated, was first aid provided?




4.2 Please list the factors that may have contributed to the incident
For example, faulty equipment, procedural failure, inadequate supervision, weather




4.3 Please conduct a risk assessment using this matrix and determine an overall risk score.

                                                        1.        How severely could it     2.   How likely is it to be that bad?
Risk Assessment                                                   hurt someone or how ill    Very likely       Likely          Unlikely       Very unlikely
Matrix                                                            could it make someone?
                                                                                            Could happen        Could       Could happen,     Could happen,
                                                                                             at any time       happen       but very rarely    but probably
Guide to risk Score                                                                                           sometime                          never will
H     Urgent/High Priority - act now
M Medium Priority – action required                             Kill or cause permanent          H                H                 H               M
this week                                                        disability or ill health
M/L Low to medium priority – Hazard                       Long term illness or serious           H                H                 M              M/L
may not need immediate action                                        injury
L     Low priority if hazard increases                   Medical attention and several           H                M                 M/L             L
risk action is required                                         days off work
                                                                    First aid needed             M               M/L                L               L


                                                                                                                          Risk Score:

4.4          Determine appropriate risk control measures for this risk according to the hierarchy of risk controls. Complete the
             following corrective action plan outlining actions to be taken to prevent similar occurrences. You should ensure that you
             consider responsibilities for implementation of the recommended risk control measures. If there are any Facilities related
             actions please ensure that the actions are logged on Helpdesk.

        Hierarchy of Risk Controls                                       ACTION TAKEN/RECOMMENDED                           WHO                   WHEN
                       Can You?

             Eliminate – (Remove the Hazard)
                            If no 
             Substitute – (Use an Alternative)
                            If no 
                Isolate – (Reduce Exposure)
                            If no 
     Redesign – (Change to Equipment or Process)
                            If no 
Administrative Controls - (eg: Change of practices, training)
                            If no 
 Personal Protective Equipment – (eg: hearing protection)




4.5          Once risk control measures are in place, you should check that these control measures are effective.

4. SIGNATURES

STAFF/STUDENT SUPERVISOR:                                               Signature:                                              Date:

HEALTH & SAFETY REP (IF INVOLVED):                                      Signature:                                              Date:
FAX COPIES OF PART A & PART B – TO ORGANISATIONAL DEVELOPMENT WITHIN 3 DAYS OF THE INCIDENT REPORT. ORIGINALS
ARE TO BE FILES WITH THE CENTRE MANAGER


FOH-01 (FOH001_Online)                                                                                                                 Issued: 10/09/2010
                                                                                                                             (Public Web Site) Page 2 of 3
                                               INCIDENT REPORTING FLOWCHART


                                                                       INCIDENT
                                                        Personal, Property, Environment, Near Miss




                                 Appropriate first aid/medical treatment if required, and Report to Supervisor.
                                 Supervisor takes steps required to protect health & safety of all persons following incident




                                 Incidents’ involving significant injury/illness or damage is immediately reported to OH&S
                                 Co-ordinator by telephone or fax. If OH&S Officer is not available, Supervisor is to report
                                 incident manager of Organisational Development



    Part A of the Incident Report Form must be completed by the involved person                     For Major or Reportable incidents the incident must
    and faxed to Organisational Development within 48 hours. If this is not possible                notified to WorkSafe as soon as possible
    the form must be completed by the supervisor or another responsible person.




                                             OH&S Co-ordinator actions receipt of Incident Report Form by:
                                                    recording on database
                                                    notification to injured/ill staff
                                                    written notification to 3rd parties – WorkSafe Victoria (within
  Non reportable Incident                            48 hrs)                                                                    Major or reportable Incident
                                                    Facilities/Institute Insurer
                                                    notification to other Institute staff if appropriate –
                                                     Management, Head of Campus, Facilities, Health & Safety
                                                     Rep
                                                    Liaison with Institute staff regarding Workcover if indicated



                                                                                              Incident Report Form (Part B, Incident Follow up) to be
                                                                                              completed for major or reportable incidents. Part A & Part B of
                                                                                              Incident Report Form sent to Organisational Development within 3
                                                                                              days of Incident Notification
                                                                                              (Reporting Department to retain copy)



                                                                                              Work area to take steps to implement Corrective Action Plan.
                                                                                              Any Facilities related issues must be logged on Helpdesk.




  Any further hazard concerns re-risk control measures, unsafe                                Once risk control measures are in place, Supervisor and
  practices reported to relevant Manager.                                                     Health and Safety Representative monitor to ensure
                                                                                              effectiveness




  OHS Co-ordinator monitors progress/resolution of OH&S
  issues & hazards. Once issues are resolved, Incident
  Recording database noted accordingly.



  Bi-monthly Incident Report provided to the OHS Committee
  for review and discussion.




FOH-01 (FOH001_Online)                                                                                                              Issued: 10/09/2010
                                                                                                                          (Public Web Site) Page 3 of 3

								
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