OHS INCIDENT REPORT FORM
PLEASE COMPLETE ALL BOXES!
Purpose: This form is used to notify Work and Training Ltd of all incident/accidents.
Completed by: The employee and their supervisor.
Names of persons
completing this form
Incident/Near Hit: An unplanned event that has not resulted in injury but had the potential to do so.
Accident: An unplanned event that has resulted in injury.
Serious Injury: A fatality or an injury or ilness that disables a person to the extent that admission to a
hospital as an in-patent is required (see page 3 notes)
Lost Time Injury Time lost from work for a period greater than 8 hrs or one complete shift.
Minor Injury Those occurrences which were not lost-time injuries and for which first aid and/or
medical treatment was administered.
Commuting All injuries that occurred during travel. This would normally include travel to technical
school for training associated with employment and travel to receive medical treatment for
an injury sustained at work.
Completed form to be sent to Work & Training Ltd within 24 hrs of the incident/accident.
Surname Other Names
Gender Date of Birth
Type of Employment Vocation
Host Employer Host Contact No
W&T Coordinator Area
Date Of Incident Time Of Incident
No Of Hours Worked Starting Time
Workers Experience In Training Provided
Nature Of The Disease Nature Of The Injury
Body Location Type (see If Multiple Location
chart on page 3) Please List.
Location Of The
What was the worker
doing at the time?
How exactly was the
injury or disease
What actions caused
List the objects or
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ANALYSIS OF CAUSES
Identify the causal factors under 4 categories
Did a hazardous condition in equipment contribute to the accident?
If the answer is ‘yes’ then comment on the defect, design and quality, correctness of the equipment and material,
maintenance, inspection and reporting procedures and any other relevant factor.
Did the location or position of the equipment, material or the worker
contribute to the accident?
If the answer is ‘yes’ then comment on the causal factors such as location, space, light, ventilation, temperature,
noise, air quality, vibration, radiation or any other relevant factors.
Did the procedure used by the worker contribute to the accident?
If the answer is ‘yes’ then comment on job procedures, any deviation from it, capabilities required, need for
personal protective equipment (PPE) etc.
Did a deficiency in management system contribute to the accident?
If the answer is ‘yes’ then comment on factors such as supervision system, corrective procedures, accountability,
training, responsibility etc.
What control measures
have been put in place?
Actions taken to
prevent a re-ocurrence
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Outcome of Incident
Incident/Accident Action Required
Estimated No of LT Rehabilitation
Rehab Start Date
Start Date Short term Finish Date Short
Duties Term duties
Start Date Permanent Date Resume
Alternative Normal Duties
Workplace Standards Notification
Authorities Notified Reported To
Under Section 47
Contact No Date Reported
Time Reported Reported By
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Notice of Serious Accidents and Dangerous Incidents; Section 47:
(1) If at a workplace, (a) a person is killed or suffers serious bodily injury or illness; or (b) a serious incident occurs as a
result of which a person could have been killed or could have suffered serious bodily injury or illness, the person
having control or management of the workplace must, by the quickest possible means, notify an inspector of
particulars of the occurrence.
1.Transportation to a hospital by ambulance. 2. An overnight stay in hospital. 3. Broken bone/s (other than finger
or toe) . 4. Dislocatiion of a joint. 5. ALL electric shocks. 6. Foreign object piercing eye. 7. Serious burn from heat,
a chemical or radiation. 8. Rollover of plant or equipment. 9. Falls from height. 10. Uncontrolled release of
pressure (Steam, gas, water, oil, etc) .
Please indicate on the
chart where the injury
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W&T CO-ORDINATOR REVIEW
Completed By To be completed by the W&T Coordinator
Action required To be completed within 48 hours of incident accident.
Completed form is to be sent to OHS Manager within 48 hours of the incident accident or
prior to new apprentice re-commencing same task
Injured Person' Details
Surname 0 Other 0 Injury 0
Coordinators Name 0 Date
Type of Contact Other
Confirm Accident Details
Confirm Supervisors Confirm Apprentice/ Trainees
Confirm Witness Statement
What Are The Discrepancies
Talked to Doctor Doctors Name
Injuries Sustained as per
Confirmed Corrective Action is
Scheduled to follow up Date
Type of Contact Other
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Completed By: Completed by W&T Rehab Coordinator, Host Supervisor/Manager, Injured
Action Required: A Return-To-Work plan is required to be prepared when a worker is
incapacitated for more than 14 days. The plan is to be drawn up within 5 days
of the 14 day limit being reached.
Stakeholders Copies of this document are to be given to the Worker, Host Employer, Insurer,
treating Doctor, W&T Payroll.
The following RTW plan has been developed for:
Surname 0 Given Names 0
Employee Number 0 Contact Number
Host Employer 0
Rehab Coordinator Contact No
Host Supervisor Contact No
Treating Doctor Contact No
Physio Contact No
Suitable Alternative Duties:
Restrictions (including specific medical)
Specific Duties To Be Avoided
Long Term Goals and/or Steps To Be Taken To Facilitate A Return To Work
Hours/Day of Work
Return Date Length Of Program
Review Dates Predicted completion
We have reviewed, understand and agree to the tasks assigned and the above medical restrictions
Worker Signed Date
Host Signed Date
Reh Co Signed Date
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