Medical Incident Report Form - Excel

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Medical Incident Report Form - Excel Powered By Docstoc
					                                              OHS INCIDENT REPORT FORM

             Important Information
                                                           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
             Definitions:
             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.
                                            Email: accidents@work-training.com
                                                                  Persons Details
             Employee Number

             Surname                                                             Other Names



             Gender                                                              Date of Birth

             Type of Employment                                                  Vocation

             Host Employer                                                       Host Contact No

             W&T Coordinator                                                     Area

                                                            Incident/Accident Details
             Date Of Incident                                                    Time Of Incident

             No Of Hours Worked                                                  Starting Time

             Workers Experience In                                               Training Provided
             Task
             Nature Of The Disease                                               Nature Of The Injury

             Body Location Type (see                                             If Multiple Location
             chart on page 3)                                                    Please List.

             Location Of The
             Incident
             What was the worker
             doing at the time?
             What happened
             unexpectantly?
             How exactly was the
             injury or disease
             sustained?
             What actions caused
             the incident?

             List the objects or
             substances involved

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7ff20865-2040-424e-a218-8aa9f2a1aac7.xls                                                                                                Page 1 of 6
                                                        ANALYSIS OF CAUSES
             Identify the causal factors under 4 categories

             1. Equipment

             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.




             2. Environment

             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.




             3. People

             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.




             4. Management

             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.




                                                        CORRECTIVE ACTION

             What control measures
             have been put in place?




             Actions taken to
             prevent a re-ocurrence




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7ff20865-2040-424e-a218-8aa9f2a1aac7.xls                                                                                           Page 2 of 6
                                                 Outcome of Incident
             Incident/Accident                                  Action Required
             Classification
             Estimated No of LT                                 Rehabilitation
             Days                                               Required?

             Rehab Start Date
             dd/mm/yy

             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


                                                       Photos
             Photograph of
             Incident/Accident




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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.
             Examples:
             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
             was sustained




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7ff20865-2040-424e-a218-8aa9f2a1aac7.xls                                                                                                        Page 4 of 6
                                                     OHS INCIDENT
                                               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
                                                      Names                             Date

               Coordinators Name 0                                                      Date

              Type of Contact                                                Other


                                                        Confirm Accident Details

              Confirm Supervisors                                            Confirm Apprentice/ Trainees
              Statement                                                      Statement

              Confirm Witness Statement

                What Are The Discrepancies



                                                                  Medical

              Talked to Doctor                                               Doctors Name

              Injuries Sustained as per
                                                                             Contact Number
              Report
                                                              Corrective Action

              Confirmed Corrective Action is
              completed

              Scheduled to follow up                                                    Date

              Type of Contact                                                Other




                       Comment




              Photos




                                                                                                              07.01.05
7ff20865-2040-424e-a218-8aa9f2a1aac7.xls                                                                    Page 5 of 6
                                           RETURN-TO-WORK PLAN

Completed By:                    Completed by W&T Rehab Coordinator, Host Supervisor/Manager, Injured
                                 Worker
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
                                                 CONTACT DETAILS
Rehab Coordinator                                           Contact No
Host Supervisor                                                  Contact No
Treating Doctor                                                  Contact No
Physio                                                           Contact No
                                                     R-T-W PLAN
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
                                      AGREEMENT
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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