Incident/Accident and Investigation Report INJURED PERSON'S DETAILS Name of Injured PersonFirstLast Area/Location Position PhoneAustralia+61Afghanistan (افغانستان)+93Albania (Shqipëri)+355Algeria (الجزائر)+213American Samoa+1Andorra+376Angola+244Anguilla+1Antigua and Barbuda+1Argentina+54Armenia (Հայաստան)+374Aruba+297Ascension Island+247Australia+61Austria (Österreich)+43Azerbaijan (Azərbaycan)+994Bahamas+1Bahrain (البحرين)+973Bangladesh (বাংলাদেশ)+880Barbados+1Belarus (Беларусь)+375Belgium (België)+32Belize+501Benin (Bénin)+229Bermuda+1Bhutan (འབྲུག)+975Bolivia+591Bosnia and Herzegovina (Босна и Херцеговина)+387Botswana+267Brazil (Brasil)+55British Indian Ocean Territory+246British Virgin Islands+1Brunei+673Bulgaria (България)+359Burkina Faso+226Burundi (Uburundi)+257Cambodia (កម្ពុជា)+855Cameroon (Cameroun)+237Canada+1Cape Verde (Kabu Verdi)+238Caribbean Netherlands+599Cayman Islands+1Central African Republic (République centrafricaine)+236Chad (Tchad)+235Chile+56China (中国)+86Christmas Island+61Cocos (Keeling) Islands+61Colombia+57Comoros (جزر القمر)+269Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo)+243Congo (Republic) (Congo-Brazzaville)+242Cook Islands+682Costa Rica+506Côte d’Ivoire+225Croatia (Hrvatska)+385Cuba+53Curaçao+599Cyprus (Κύπρος)+357Czech Republic (Česká republika)+420Denmark (Danmark)+45Djibouti+253Dominica+1Dominican Republic (República Dominicana)+1Ecuador+593Egypt (مصر)+20El Salvador+503Equatorial Guinea (Guinea Ecuatorial)+240Eritrea+291Estonia (Eesti)+372Eswatini+268Ethiopia+251Falkland Islands (Islas Malvinas)+500Faroe Islands (Føroyar)+298Fiji+679Finland (Suomi)+358France+33French Guiana (Guyane française)+594French Polynesia (Polynésie française)+689Gabon+241Gambia+220Georgia (საქართველო)+995Germany (Deutschland)+49Ghana (Gaana)+233Gibraltar+350Greece (Ελλάδα)+30Greenland (Kalaallit Nunaat)+299Grenada+1Guadeloupe+590Guam+1Guatemala+502Guernsey+44Guinea (Guinée)+224Guinea-Bissau (Guiné Bissau)+245Guyana+592Haiti+509Honduras+504Hong Kong (香港)+852Hungary (Magyarország)+36Iceland (Ísland)+354India (भारत)+91Indonesia+62Iran (ایران)+98Iraq (العراق)+964Ireland+353Isle of Man+44Israel (ישראל)+972Italy (Italia)+39Jamaica+1Japan (日本)+81Jersey+44Jordan (الأردن)+962Kazakhstan (Казахстан)+7Kenya+254Kiribati+686Kosovo+383Kuwait (الكويت)+965Kyrgyzstan (Кыргызстан)+996Laos (ລາວ)+856Latvia (Latvija)+371Lebanon (لبنان)+961Lesotho+266Liberia+231Libya (ليبيا)+218Liechtenstein+423Lithuania (Lietuva)+370Luxembourg+352Macau (澳門)+853Macedonia (FYROM) (Македонија)+389Madagascar (Madagasikara)+261Malawi+265Malaysia+60Maldives+960Mali+223Malta+356Marshall Islands+692Martinique+596Mauritania (موريتانيا)+222Mauritius (Moris)+230Mayotte+262Mexico (México)+52Micronesia+691Moldova (Republica Moldova)+373Monaco+377Mongolia (Монгол)+976Montenegro (Crna Gora)+382Montserrat+1Morocco (المغرب)+212Mozambique (Moçambique)+258Myanmar (Burma) (မြန်မာ)+95Namibia (Namibië)+264Nauru+674Nepal (नेपाल)+977Netherlands (Nederland)+31New Caledonia (Nouvelle-Calédonie)+687New Zealand+64Nicaragua+505Niger (Nijar)+227Nigeria+234Niue+683Norfolk Island+672North Korea (조선 민주주의 인민 공화국)+850Northern Mariana Islands+1Norway (Norge)+47Oman (عُمان)+968Pakistan (پاکستان)+92Palau+680Palestine (فلسطين)+970Panama (Panamá)+507Papua New Guinea+675Paraguay+595Peru (Perú)+51Philippines+63Poland (Polska)+48Portugal+351Puerto Rico+1Qatar (قطر)+974Réunion (La Réunion)+262Romania (România)+40Russia (Россия)+7Rwanda+250Saint Barthélemy+590Saint Helena+290Saint Kitts and Nevis+1Saint Lucia+1Saint Martin (Saint-Martin (partie française))+590Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)+508Saint Vincent and the Grenadines+1Samoa+685San Marino+378São Tomé and Príncipe (São Tomé e Príncipe)+239Saudi Arabia (المملكة العربية السعودية)+966Senegal (Sénégal)+221Serbia (Србија)+381Seychelles+248Sierra Leone+232Singapore+65Sint Maarten+1Slovakia (Slovensko)+421Slovenia (Slovenija)+386Solomon Islands+677Somalia (Soomaaliya)+252South Africa+27South Korea (대한민국)+82South Sudan (جنوب السودان)+211Spain (España)+34Sri Lanka (ශ්රී ලංකාව)+94Sudan (السودان)+249Suriname+597Svalbard and Jan Mayen+47Sweden (Sverige)+46Switzerland (Schweiz)+41Syria (سوريا)+963Taiwan (台灣)+886Tajikistan+992Tanzania+255Thailand (ไทย)+66Timor-Leste+670Togo+228Tokelau+690Tonga+676Trinidad and Tobago+1Tunisia (تونس)+216Turkey (Türkiye)+90Turkmenistan+993Turks and Caicos Islands+1Tuvalu+688U.S. Virgin Islands+1Uganda+256Ukraine (Україна)+380United Arab Emirates (الإمارات العربية المتحدة)+971United Kingdom+44United States+1Uruguay+598Uzbekistan (Oʻzbekiston)+998Vanuatu+678Vatican City (Città del Vaticano)+39Venezuela+58Vietnam (Việt Nam)+84Wallis and Futuna (Wallis-et-Futuna)+681Western Sahara (الصحراء الغربية)+212Yemen (اليمن)+967Zambia+260Zimbabwe+263Åland Islands+358 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)Australia+61Afghanistan (افغانستان)+93Albania (Shqipëri)+355Algeria (الجزائر)+213American Samoa+1Andorra+376Angola+244Anguilla+1Antigua and Barbuda+1Argentina+54Armenia (Հայաստան)+374Aruba+297Ascension Island+247Australia+61Austria (Österreich)+43Azerbaijan (Azərbaycan)+994Bahamas+1Bahrain (البحرين)+973Bangladesh (বাংলাদেশ)+880Barbados+1Belarus (Беларусь)+375Belgium (België)+32Belize+501Benin (Bénin)+229Bermuda+1Bhutan (འབྲུག)+975Bolivia+591Bosnia and Herzegovina (Босна и Херцеговина)+387Botswana+267Brazil (Brasil)+55British Indian Ocean Territory+246British Virgin Islands+1Brunei+673Bulgaria (България)+359Burkina Faso+226Burundi (Uburundi)+257Cambodia (កម្ពុជា)+855Cameroon (Cameroun)+237Canada+1Cape Verde (Kabu Verdi)+238Caribbean Netherlands+599Cayman Islands+1Central African Republic (République centrafricaine)+236Chad (Tchad)+235Chile+56China (中国)+86Christmas Island+61Cocos (Keeling) Islands+61Colombia+57Comoros (جزر القمر)+269Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo)+243Congo (Republic) (Congo-Brazzaville)+242Cook Islands+682Costa Rica+506Côte d’Ivoire+225Croatia (Hrvatska)+385Cuba+53Curaçao+599Cyprus (Κύπρος)+357Czech Republic (Česká republika)+420Denmark (Danmark)+45Djibouti+253Dominica+1Dominican Republic (República Dominicana)+1Ecuador+593Egypt (مصر)+20El Salvador+503Equatorial Guinea (Guinea Ecuatorial)+240Eritrea+291Estonia (Eesti)+372Eswatini+268Ethiopia+251Falkland Islands (Islas Malvinas)+500Faroe Islands (Føroyar)+298Fiji+679Finland (Suomi)+358France+33French Guiana (Guyane française)+594French Polynesia (Polynésie française)+689Gabon+241Gambia+220Georgia (საქართველო)+995Germany (Deutschland)+49Ghana (Gaana)+233Gibraltar+350Greece (Ελλάδα)+30Greenland (Kalaallit Nunaat)+299Grenada+1Guadeloupe+590Guam+1Guatemala+502Guernsey+44Guinea (Guinée)+224Guinea-Bissau (Guiné Bissau)+245Guyana+592Haiti+509Honduras+504Hong Kong (香港)+852Hungary (Magyarország)+36Iceland (Ísland)+354India (भारत)+91Indonesia+62Iran (ایران)+98Iraq (العراق)+964Ireland+353Isle of Man+44Israel (ישראל)+972Italy (Italia)+39Jamaica+1Japan (日本)+81Jersey+44Jordan (الأردن)+962Kazakhstan (Казахстан)+7Kenya+254Kiribati+686Kosovo+383Kuwait (الكويت)+965Kyrgyzstan (Кыргызстан)+996Laos (ລາວ)+856Latvia (Latvija)+371Lebanon (لبنان)+961Lesotho+266Liberia+231Libya (ليبيا)+218Liechtenstein+423Lithuania (Lietuva)+370Luxembourg+352Macau (澳門)+853Macedonia (FYROM) (Македонија)+389Madagascar (Madagasikara)+261Malawi+265Malaysia+60Maldives+960Mali+223Malta+356Marshall Islands+692Martinique+596Mauritania (موريتانيا)+222Mauritius (Moris)+230Mayotte+262Mexico (México)+52Micronesia+691Moldova (Republica Moldova)+373Monaco+377Mongolia (Монгол)+976Montenegro (Crna Gora)+382Montserrat+1Morocco (المغرب)+212Mozambique (Moçambique)+258Myanmar (Burma) (မြန်မာ)+95Namibia (Namibië)+264Nauru+674Nepal (नेपाल)+977Netherlands (Nederland)+31New Caledonia (Nouvelle-Calédonie)+687New Zealand+64Nicaragua+505Niger (Nijar)+227Nigeria+234Niue+683Norfolk Island+672North Korea (조선 민주주의 인민 공화국)+850Northern Mariana Islands+1Norway (Norge)+47Oman (عُمان)+968Pakistan (پاکستان)+92Palau+680Palestine (فلسطين)+970Panama (Panamá)+507Papua New Guinea+675Paraguay+595Peru (Perú)+51Philippines+63Poland (Polska)+48Portugal+351Puerto Rico+1Qatar (قطر)+974Réunion (La Réunion)+262Romania (România)+40Russia (Россия)+7Rwanda+250Saint Barthélemy+590Saint Helena+290Saint Kitts and Nevis+1Saint Lucia+1Saint Martin (Saint-Martin (partie française))+590Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)+508Saint Vincent and the Grenadines+1Samoa+685San Marino+378São Tomé and Príncipe (São Tomé e Príncipe)+239Saudi Arabia (المملكة العربية السعودية)+966Senegal (Sénégal)+221Serbia (Србија)+381Seychelles+248Sierra Leone+232Singapore+65Sint Maarten+1Slovakia (Slovensko)+421Slovenia (Slovenija)+386Solomon Islands+677Somalia (Soomaaliya)+252South Africa+27South Korea (대한민국)+82South Sudan (جنوب السودان)+211Spain (España)+34Sri Lanka (ශ්රී ලංකාව)+94Sudan (السودان)+249Suriname+597Svalbard and Jan Mayen+47Sweden (Sverige)+46Switzerland (Schweiz)+41Syria (سوريا)+963Taiwan (台灣)+886Tajikistan+992Tanzania+255Thailand (ไทย)+66Timor-Leste+670Togo+228Tokelau+690Tonga+676Trinidad and Tobago+1Tunisia (تونس)+216Turkey (Türkiye)+90Turkmenistan+993Turks and Caicos Islands+1Tuvalu+688U.S. Virgin Islands+1Uganda+256Ukraine (Україна)+380United Arab Emirates (الإمارات العربية المتحدة)+971United Kingdom+44United States+1Uruguay+598Uzbekistan (Oʻzbekiston)+998Vanuatu+678Vatican City (Città del Vaticano)+39Venezuela+58Vietnam (Việt Nam)+84Wallis and Futuna (Wallis-et-Futuna)+681Western Sahara (الصحراء الغربية)+212Yemen (اليمن)+967Zambia+260Zimbabwe+263Åland Islands+358 Email (Witness 1) Name (Witness 2)FirstLast Phone (Witness 2)Australia+61Afghanistan (افغانستان)+93Albania (Shqipëri)+355Algeria (الجزائر)+213American Samoa+1Andorra+376Angola+244Anguilla+1Antigua and Barbuda+1Argentina+54Armenia (Հայաստան)+374Aruba+297Ascension Island+247Australia+61Austria (Österreich)+43Azerbaijan (Azərbaycan)+994Bahamas+1Bahrain (البحرين)+973Bangladesh (বাংলাদেশ)+880Barbados+1Belarus (Беларусь)+375Belgium (België)+32Belize+501Benin (Bénin)+229Bermuda+1Bhutan (འབྲུག)+975Bolivia+591Bosnia and Herzegovina (Босна и Херцеговина)+387Botswana+267Brazil (Brasil)+55British Indian Ocean Territory+246British Virgin Islands+1Brunei+673Bulgaria (България)+359Burkina Faso+226Burundi (Uburundi)+257Cambodia (កម្ពុជា)+855Cameroon (Cameroun)+237Canada+1Cape Verde (Kabu Verdi)+238Caribbean Netherlands+599Cayman Islands+1Central African Republic (République centrafricaine)+236Chad (Tchad)+235Chile+56China (中国)+86Christmas Island+61Cocos (Keeling) Islands+61Colombia+57Comoros (جزر القمر)+269Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo)+243Congo (Republic) (Congo-Brazzaville)+242Cook Islands+682Costa Rica+506Côte d’Ivoire+225Croatia (Hrvatska)+385Cuba+53Curaçao+599Cyprus (Κύπρος)+357Czech Republic (Česká republika)+420Denmark (Danmark)+45Djibouti+253Dominica+1Dominican Republic (República Dominicana)+1Ecuador+593Egypt (مصر)+20El Salvador+503Equatorial Guinea (Guinea Ecuatorial)+240Eritrea+291Estonia (Eesti)+372Eswatini+268Ethiopia+251Falkland Islands (Islas Malvinas)+500Faroe Islands (Føroyar)+298Fiji+679Finland (Suomi)+358France+33French Guiana (Guyane française)+594French Polynesia (Polynésie française)+689Gabon+241Gambia+220Georgia (საქართველო)+995Germany (Deutschland)+49Ghana (Gaana)+233Gibraltar+350Greece (Ελλάδα)+30Greenland (Kalaallit Nunaat)+299Grenada+1Guadeloupe+590Guam+1Guatemala+502Guernsey+44Guinea (Guinée)+224Guinea-Bissau (Guiné Bissau)+245Guyana+592Haiti+509Honduras+504Hong Kong (香港)+852Hungary (Magyarország)+36Iceland (Ísland)+354India (भारत)+91Indonesia+62Iran (ایران)+98Iraq (العراق)+964Ireland+353Isle of Man+44Israel (ישראל)+972Italy (Italia)+39Jamaica+1Japan (日本)+81Jersey+44Jordan (الأردن)+962Kazakhstan (Казахстан)+7Kenya+254Kiribati+686Kosovo+383Kuwait (الكويت)+965Kyrgyzstan (Кыргызстан)+996Laos (ລາວ)+856Latvia (Latvija)+371Lebanon (لبنان)+961Lesotho+266Liberia+231Libya (ليبيا)+218Liechtenstein+423Lithuania (Lietuva)+370Luxembourg+352Macau (澳門)+853Macedonia (FYROM) (Македонија)+389Madagascar (Madagasikara)+261Malawi+265Malaysia+60Maldives+960Mali+223Malta+356Marshall Islands+692Martinique+596Mauritania (موريتانيا)+222Mauritius (Moris)+230Mayotte+262Mexico (México)+52Micronesia+691Moldova (Republica Moldova)+373Monaco+377Mongolia (Монгол)+976Montenegro (Crna Gora)+382Montserrat+1Morocco (المغرب)+212Mozambique (Moçambique)+258Myanmar (Burma) (မြန်မာ)+95Namibia (Namibië)+264Nauru+674Nepal (नेपाल)+977Netherlands (Nederland)+31New Caledonia (Nouvelle-Calédonie)+687New Zealand+64Nicaragua+505Niger (Nijar)+227Nigeria+234Niue+683Norfolk Island+672North Korea (조선 민주주의 인민 공화국)+850Northern Mariana Islands+1Norway (Norge)+47Oman (عُمان)+968Pakistan (پاکستان)+92Palau+680Palestine (فلسطين)+970Panama (Panamá)+507Papua New Guinea+675Paraguay+595Peru (Perú)+51Philippines+63Poland (Polska)+48Portugal+351Puerto Rico+1Qatar (قطر)+974Réunion (La Réunion)+262Romania (România)+40Russia (Россия)+7Rwanda+250Saint Barthélemy+590Saint Helena+290Saint Kitts and Nevis+1Saint Lucia+1Saint Martin (Saint-Martin (partie française))+590Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)+508Saint Vincent and the Grenadines+1Samoa+685San Marino+378São Tomé and Príncipe (São Tomé e Príncipe)+239Saudi Arabia (المملكة العربية السعودية)+966Senegal (Sénégal)+221Serbia (Србија)+381Seychelles+248Sierra Leone+232Singapore+65Sint Maarten+1Slovakia (Slovensko)+421Slovenia (Slovenija)+386Solomon Islands+677Somalia (Soomaaliya)+252South Africa+27South Korea (대한민국)+82South Sudan (جنوب السودان)+211Spain (España)+34Sri Lanka (ශ්රී ලංකාව)+94Sudan (السودان)+249Suriname+597Svalbard and Jan Mayen+47Sweden (Sverige)+46Switzerland (Schweiz)+41Syria (سوريا)+963Taiwan (台灣)+886Tajikistan+992Tanzania+255Thailand (ไทย)+66Timor-Leste+670Togo+228Tokelau+690Tonga+676Trinidad and Tobago+1Tunisia (تونس)+216Turkey (Türkiye)+90Turkmenistan+993Turks and Caicos Islands+1Tuvalu+688U.S. Virgin Islands+1Uganda+256Ukraine (Україна)+380United Arab Emirates (الإمارات العربية المتحدة)+971United Kingdom+44United States+1Uruguay+598Uzbekistan (Oʻzbekiston)+998Vanuatu+678Vatican City (Città del Vaticano)+39Venezuela+58Vietnam (Việt Nam)+84Wallis and Futuna (Wallis-et-Futuna)+681Western Sahara (الصحراء الغربية)+212Yemen (اليمن)+967Zambia+260Zimbabwe+263Åland Islands+358 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
