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LCA SA NT REF HSE 012 Incident Report Form LCA Insurance Form

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LCA SA NT REF HSE 012 Incident Report Form LCA Insurance Form Powered By Docstoc
					        INCIDENT REPORT FORM - LCA Insurance                                                             LCA_SA_NT_REF_HSE_012

PART 1 INCIDENT DETAILS


Name of Injured Person …………………………………………………………………………… DOB …………………..

Phone …………………………………. Home Address …………………………………………………………………………

…………………………………………………………………………………………………… Postcode ………………………….

Occupation …………………………………………………………… [ ] Employee [ ] Volunteer [ ] Guest [ ] Other

Date of Incident …………………………………………. Time of Incident ……………………………………………......

Location of incident ……………………………………………………………………………………………………………..……

Circumstances of Incident (cause of incident; what was happening preceding the incident; trip, fall)
………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………

Nature of injuries (location on body; severity; type of injury - bruise, fracture, puncture, twisted ankle, etc)
………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………

Any Witnesses [ ] NO [ ] YES              If Yes, witness statements [ ] requested, obtained & attached (signed / dated)

                                                                      [ ] requested but not provided



PART 2 IMMEDIATE RESPONSE DETAILS


Describe what action was taken (be specific & factual; record sequential order - timing; any first aid treatment; phoned 000 -any police report
number; contacted family or relatives; photographs taken; etc)

………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………

Name - Doctor / Nurse / Other ………………………………………………………………………………........................

Phone contact details ………………………………………………………………………………………………………….

Location of - Medical Centre / Doctor Surgery / Hospital (circle) ………………………………………………………..

……………………………………………………………………………… Phone …………………………………………….




             Document Version 1.0                          Next Document Review Date 12/2014                                1
PART 3 ASSESSMENT and CORRECTIVE ACTIONS - Risk management


Probable cause of incident (highlight whatever is appropriate): inadequate instruction / inadequate workspace / assistance
unavailable / fault of plant or equipment / equipment unavailable / lack of attention / poor storage / poor access / incorrect
method or work practices / weather / terrain
………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………
Other cause (please specify) ………………………………………………………………………………………………………

Injured person (if applicable) [ ] trained [ ] experienced [ ] protective clothing / equipment used

Supervisor name (if applicable) ……………………………………………………………………………………………………………..

Phone contact ………………………………………………… Any pertinent warnings / instructions given? (circle) Yes / No

What steps must be taken to prevent a recurrence? (short term / longer term)
………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………

By whom? ……………………………………………………………………………………………………………………….

Anticipated completion date ………………………………………………………………………………………………….




PART 4 REVIEW of CORRECTIVE ACTIONS


Corrective actions reviewed on ………………………………………… by ………………………………………………

Status [ ] complete [ ] incomplete - comment
………………………………………………………………………………………………………………………………………

Corrective actions reviewed on ………………………………………… by ………………………………………………

Status …………………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………………………


PART 5 NOTIFICATION               NOTE: if a notifiable ‘dangerous occurrence’ occurs, notify
                                            www.safework.sa.gov.au
                                            www.worksafe.nt.gov.au


Organisation name / location …………………………………………………………………………………………………
…………………………………………………………………………………………………..................................................

Contact person (Chairman / Treasurer / Pastor / OHS Officer) ………………………………………………………………………

Phone ………………………………………… Filed in Incident Register on ………………..…by ……………………..

Forwarded to District Administrator (if applicable) on ……………………… Signed …………………………………….




           Document Version 1.0                      Next Document Review Date 12/2014                    2

				
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