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F53. Incident investigation
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Form
9
F53. Incident investigation
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Post Type Selectors
Unique ID
Project
Sample Project with Related Forms
Test Project
Test Card
Test Project 1
New Project
Incident Report
Report Date
DD slash MM slash YYYY
Project Name
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On-site location
Interviewing Person
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Location/address of Site
Date of Incident
DD slash MM slash YYYY
Time of Incident
Hours
:
Minutes
AM
PM
AM/PM
Day of week on which incident occurred
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday.
Witnesses (Staff Name)
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Witnesses (Contractor Name)
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The incident occurred
inside the building
outside of the building
site wide
Other
If the incident occurred outside, what was the weather?
sunny
raining
windy
overcast
dusty
frost
snow
sleeting
Type of Incident
Death
Machinery damage
Interruption to work
Personal Injury
Environmental damage
Property damage
Incident Investigation
Incident Classification
Incident
Near Miss
Dangerous event
Questions
Chemical Spill or loss of Chemical
Yes
No
Caused by:
Other loss or damage:
Add
Remove
Did this situation have the potential to cause harm?
Yes
No
Name and role title of party who approved work to commence:
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Role
Details of immediate/temporary controls implemented:
General information
Who was the first person at the accident?
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Was anyone working with the injured person?
Yes
No
Who was working with the injured person?
Name
Contact
Add
Remove
Has an incident notification been completed?
Yes
No
Who administered first aid?
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Was medical attention required?
Yes
No
Was the worker admitted to hospital?
Yes
No
When is the worker expected to return to work?
DD slash MM slash YYYY
Are safe housekeeping practices followed?
Yes
No
Task
Has the worker performed this task before?
Yes
No
How long?
New to task
In training
Less than 3 months
Less than 6 months
Experienced worker
What task was being performed?
Is there a written standard procedure?
Yes
No
If so, was it followed?
Yes
No
Is there a need for a new procedure?
Yes
No
Does the worker have a current valid VOC?
Yes
No
Validator of VOC (Name)
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Contact
Was a risk assessment conducted and approved?
Yes
No
Approval of risk assessment (Name)
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Contact
Supervision
Was the worker supervised?
Yes
No
Supervisor(Name)
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Contact
Is there evidence of supervision?
Yes
No
Provide details of evidence – Upload document / photo
Were safety inspections conducted?
Yes
No
Safety inspections conducted by:(Name)
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Contact
What issues were found by the inspection?
Add
Remove
Were the issues addressed?
Yes
No
Details of those who addressed issues:(Name)
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Contact
Was management informed?
Yes
No
Informed management: (Name)
– No Results –
Contact
Equipment
What was the equipment being used?
Equipment Type
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Confirm it was in good condition
Yes
No
Provide Details
Prestart conducted by: (Name)
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Contact
Manufacturer’s instructions, & SOP available?
Yes
No
Where are they located?
Machine
Vehicle
Job file
Site office
Workshop
Other
Other Details
Is the maintenance up to date?
Yes
No
Was the operator deemed as competent?
Yes
No
Approved competence (Name)
– No Results –
Contact
Environmental damage
What environmental damage was sustained?
What environmental damage was sustained? - Upload document / photo
Did Control Plan address the issues?
Yes
No
Have temporary controls been installed?
Yes
No
Evidence Gathered
Statements obtained - Upload document / photo
Contact
Photographs included:
Subject of photograph
Add
Remove
Upload document / photo
Other Evidence:
Description
Add
Remove
Upload document / photo
WHS Management System
OH&S management system address this issue?
Yes
No
Has the Management System been reviewed?
Yes
No
Reviewer of management system: (Name)
– No Results –
Contact
Have previous reports been considered?
Yes
No
Reviewer of previous reports
– No Results –
Contact
In your opinion what contributed directly to the incident:
Findings/Action Required
Comment for what to fix
What further training is required?
Is more supervision required?
Yes
No
Are SOP required to be updated or written?
Yes
No
HSR to be elected and consultation undertaken?
Yes
No
Should our Management System be reviewed?
Yes
No
Expected completion
DD slash MM slash YYYY
Section Break
