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									                         Catholic Safety Health & Welfare SA


                                   INSTRUCTIONS                                          NOTIFICATION OF CERTAIN WORK RELATED
                                                                                         INJURIES AND DANGEROUS OCCURRENCES
              This form is to be used to report all incidents and                             OHS&W Regulations 1995 Pt 6 Div. 6.6
accidents including 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
                                                                              Have you contacted your OHS Consultant?                Yes  No
                   consultation with ALL affected parties.
                                                                              NOTE: CSH&W after hours ph 0438396062
Part C –          Completed in the case of a sustained injury by either
                                                                              Has SafeWork SA been notified within 24 hrs?           Yes  No
                  the person involved and/or the person conducting the
                                                                              SafeWork SA contact No: 1800 777 209
If a claim is to be lodged please forward a copy of the full report to CCI    Ref no._______________
within 3 working days from the date of the injury.

WORKSITE: The Old Folks Aged Care
ADDRESS Elderly Road, Seniorsville SA
PHONE: 8634 9871                                                                    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

 Injury (No lost time)                                                 Volunteer                             Other __________________________

Date of Incident        01/12/2008                                           Time of Incident                 09:00                           AM/PM
Date Reported           01/12/2008                                           Time Reported                    09:30                           AM/PM
Reported to             Margaret Lewis
Describe briefly what happened:
Gino was in the storeroom looking for a mop when the middle shelf of the shelving unit against the eastern wall collapsed and all the
contents on the shelf fell to the floor.

  D:\Docstoc\Working\pdf\cb4391bd-cb50-4f89-b195-7be7558460c4.doc                                                                                    1
  Review Date: January 2010
                  Catholic Safety Health & Welfare SA

                                                                                                                  PART A

Stavropoulous                                           Gino
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 Cleaner

Contact Phone No. (Wk) 8634 9871         (Hm) 8789 3561             (Mob) 0488 345 281

Home Address 32 Long Road, Newton, SA

NAME OF PERSON SUBMITTING DETAILS: (if differenet from above)

Heyes                                            Elizabeth May
Surname                                          Given Name/s

Contact Phone No.(Wk) 8634 9871          (Hm) 8602 7810             (Mob) 0487 126 925


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:    01 / 12 / 2008
EXACT LOCATION OF INCIDENT: eg. Particular building/room, while in transit (vehicle etc)

The storeroom of the northern wing.

plant/substance/equipment involved

Looking for a mop.

WHAT HAPPENED? Please include a description of events:

Gino was looking for a new mop and was told by the house keeping manager that new mops had just been delivered and they
were in the storeroom of the north wing.

Gino entered the storeroom and just as he saw the mops, that were standing by the western wall adjacent to the door, he heard
a crash and looked behind him to see that the middle shelf of the shelving unit on the eastern wall had collapsed and all the
contents of the shelf had fallen onto the floor. The shelves below were not affected.

D:\Docstoc\Working\pdf\cb4391bd-cb50-4f89-b195-7be7558460c4.doc                                                             2
Review Date: January 2010
                       Catholic Safety Health & Welfare SA

    People: (eg culture, language, fatigue?) N/A

    Total hours worked when incident occurred 1 hr

    Environment: (eg lighting, temperature, wind?) There was adequate lighting in the storeroom.

    Plant/Equipment: (eg guarding, maintenance, type of plant/equipment?) N/A

    Materials: (eg suitable for task, clothing, footwear, personal protective equipment, materials used?) The metal shelving unit was
    constructed of light grade metal and signage on the shelving unit indicated that not more than 75 kilograms should be placed
    on each shelf. The combined weight of the boxes was 135 kilograms.

    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 –
             Immediate clean up of spillage. Spilt boxes placed against southern wall.
             All other boxes removed from other shelves.
             Maintenance inspected integrity of other shelves of the unit.
             Obtained appropriate scale and bench on which scales were placed and weighed each box and only placed maximum
              weight of 70 kilograms back onto other shelves.
             Excess boxes stacked safely against southern wall.
             Ensured safe manual handing practices were observed.

    Interim Controls: (Short Term)
             Reviewed SOP for stacking of shelves in all store rooms.
             Inspected all other shelving units.
             Placed scales in each storeroom and a log to record the weight of each shelf.
             Provide employees with information and training of the requirements to weight the boxes and record the weight in the
              log book.

    Proposed Permanent Controls –
             Purchase new industrial grade shelving units that can accommodate a maximum of 150 kilos on each shelf in
              consultation with employees.
             Provide information and training to employees in relation to the new shelving units.

    Action plan/Hazard Register updated       Yes      No     Ref No 08 095 Risk Assessment Ref No OFAC 136

             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

    Review Date: January 2010                                                                                                           3
                     Catholic Safety Health & Welfare SA

    Has feedback been provided to person/s involved in the incident:  Yes Date: 05 / 12 / 08  No

                                                                                                         SIGN OFF
    SUPERVISOR / MANAGER – I confirm the details of the incident reported and agree with the recommendations made.

Name: Stephen Bowes _____________________ Date:            05 / 12      / 08      Ph: 8634 9871   _____________________

Signed: _______________________________________________

Name of person Investigating incident: Stephen Bowes _______                   Comments:

Signature: _______________________ Date:            05   / 12    / 08

Name of Health and Safety Representative: Joan Petersen _____                  Comments:

Signature: _______________________ Date:            05   / 12    / 08

    Review Date: January 2010                                                                                             4
                               Catholic Safety Health & Welfare SA
                                                                                                                                    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
                              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

           Review Date: January 2010                                                                                                                   5

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