Incident/Accident and Investigation Report INJURED PERSON'S DETAILS Name of Injured PersonFirstLast Area/Location Position Phone Email (Injured Person) Please TickEmployeeContractorCompanyCustomerPublicDETAILS OF THE ACCIDENT Date of Incident Operation the worker/contractor was engaged in at the time of the incidentDETAILS OF THE TREATMENT What treatment was provided? [please tick]NILFirst AidMedical PractitionerHospital If you went to hospital or were seen by a medical practitioner, provide more detail (otherwise skip) Details of Treatment Was there any time lost [please tick]NILRemainder of the dayOther Workers Compensation Claim LodgedYesNoOtherABOUT THE INJURY [ TICK APPROPRIATE BOX] Cause of InjuryPushing/FallingTrip/Slip/FallFalling ObjectVehicleHit ByHit AgainstChemicalOther If other, explain (cause of injury) Nature of InjuryCutBruiseSprain/StrainElectric ShockFracturePunctureBurnAbrasionOther If other, explain (nature of injury) What body parts were affected?HeadHand (right)Hand (left)FingersFaceKnee (right)Knee (left)Ankle (right)Ankle (left)Eye (right)Eye (left)Leg (right)Leg (left)NoseEarsBackNeckFoot (right)Foot (left)Arm (right)Arm (left)Other If other, explain (body part affected)THE INCIDENT Were there any witnesses? YesNoOtherIf yes, please list names below Name (Witness 1)FirstLast Phone (Witness 1) Email (Witness 1) Name (Witness 2)FirstLast Phone (Witness 2) Email (Witness 2)INCIDENT ANALYSISWhat contributed to the incident: [describe the factors that contributed to the incident] Work Organisation Work Methods Work Environment Work Equipment/Plant Employees Behaviour ConclusionsPREVENTION What was the IMMEDIATE action taken following the incident or accident? What action will be taken to prevent a recurrence?INVESTIGATION OF INCIDENTIncident investigated by: Name (Investigator)FirstLast Position (Investigator) DateManager: Name (Manager)FirstLast Position (Manager) reCAPTCHASubmitReset
