Incident Report 2zb3a

SA GENEALOGICAL & HERALDRY SOCIETY ACCIDENT/INCIDENT REPORT and INVESTIGATION FORM      

Date report is being made:

This form is to be used for ALL accidents, or near misses, whether an injury occurred or not PART A:

ACCIDENT / INCIDENT REPORT FORM TO BE COMPLETED BY PERSON INVOLVED (or by supervisor or if person is incapacitated then by nearest relative)

Please complete within 24 hours of the accident. If the accident caused, or could have caused, serious injury or property damage, please SAGHS on 08 8272 4222 immediately.

1: INFORMATION ABOUT THE PERSON MAKING THE REPORT (please print) Title Dr

Mr

Surname or Family name Mrs

Given Name

     

Date of Birth

     

     

Ms Status:

Gender:

Employee

Volunteer

Contractor

Visitor

Occupation:

Member

Male

Female

     

Other (describe)

     

     

telephone number

Are you currently employed? Name of employer:

     

Address:

     

YES

NO

If yes, please provide employer details

     

Post Code:

Will you require time off work?

YES

NO

Approximately how long will you be off work?      

What type of event is this? Where did it occur?

Accident

    

days

Incident

     

weeks

Near Miss

unknown

Medical

      Have you already reported the accident / incident / near miss?

If YES, who did you report it to?

Name

     

YES Date

NO      

Reported

2: WHAT PART OF THE BODY WAS AFFECTED (tick appropriate answers) Head

Trunk

Eye Ear Nose

Neck Hip Chest

Mouth

Stomach

Teeth Face Skull

Groin Back Multiple

Internal Heart Lungs Systemic

Arm

Hand

Leg

Left Right Shoulder

Left Right Thumb

Left Right Knee

Upper Arm Elbow Forearm Wrist

Fingers

Lower Leg

Accident / Incident Report & Investigation Form Version 1: 2004 Date Printed: 6/04/2013

Foot Left Right Great Toe Other Toes

Ankle Thigh

Page1 of 3

SA GENEALOGICAL & HERALDRY SOCIETY ACCIDENT/INCIDENT REPORT and INVESTIGATION FORM 3: NATURE OF INJURY (tick appropriate answers) Abrasion

Puncture

Heart Attack

Sprain

Burn

Traumatic Shock

Bruise Laceration Hearing Loss Strain Scald Fracture Amputation Foreign Body Hernia Rash Concussion Bite Minor Cuts Allergy Aggravation of previous injury or medical condition, or other injury not already specified. (describe)

Electric Shock Psychosocial Chemical

     

4: HOW DID THE ACCIDENT/INCIDENT OCCUR (tick appropriate answers) Striking Against Struck By Caught In Stepping On Other: Describe

Stumbling Slipping Tripping Falling      

Lifting Bending Twisting Stress

Pushing Pulling Jumping Motor Vehicle

Ingestion Absorption Inhalation

5: AGENCY OF INJURY (tick) Vehicle

Buildings

Mobile Plant

Structures

Power tools Animal/Insect Biological agent Objects

Furniture Heat Stress Chemicals Ionising radiation

Other tools Materials Equipment

Surfaces Sunburn Stress

Signed: PART B:

     

Date:

INVESTIGATION FORM TO BE COMPLETED BY THE SUPERVISOR AND/OR DELEGATED OFFICER WITHIN 48 HRS OF NOTIFICATION IMPORTANT: This part of the process is designed to prevent recurrences

1: PROBABLE CAUSE/S OF ACCIDENT / INCIDENT (tick appropriate answers) Inadequate Instruction Inadequate Workspace Assistance Unavailable Other (Describe)      

Fault Of Plant Or Equipment Equipment Unavailable Lack Of Attention

Poor Storage Poor Access Incorrect Method

Weather Terrain Work Practices

2: DESCRIBE THE ACCIDENT / INCIDENT                        

3: RATE THE POTENTIAL SEVERITY OF THE ACCIDENT / INCIDENT (e.g. what could have happened?) Low (eg first aid treatment)

Moderate (eg medical attention)

High (eg ambulance or other emergency services)

Accident / Incident Report & Investigation Form Version 1: 2004 Date Printed: 6/04/2013

Severe (eg death or severe disablement)

Page2 of 3

SA GENEALOGICAL & HERALDRY SOCIETY ACCIDENT/INCIDENT REPORT and INVESTIGATION FORM 4: PREVENTION OF ACCIDENT/INCIDENT RECURRENCE Describe what action is planned or has been taken to prevent a recurrence of the accident/ incident, based on the key contributing factors (Please print) Immediate action taken

           

Suggested long term action

                       

IS TRAINING REQUIRED? Induction Task specific Area specific

YES YES YES

NO NO NO

REHABILITATION Is required Is not required Unknown as yet Time Off Work Required.

5: ISTRATION Investigation undertaken by supervisor or delegated officer Print name:

     

Date investigation completed:

     

Signature: A copy of this report must be provided to the person making the report. The original must be retained by SAGHS copy provided to person making report

Accident / Incident Report & Investigation Form Version 1: 2004 Date Printed: 6/04/2013

Date

     

Page3 of 3