Incident Investigation FormTo be completed by the Supervisor/Manager (All fields mandatory)

Please refer to the Incident Reporting and Investigation Guideline to assist with the completion of this form. All investigations must be undertaken by the Supervisor/Manager in consultation with the Elected Health and Safety Representative.

Part 1. Incident Details An online incident notification form should have been completed prior to this form.

Name of Person Injured or Involved in the incident/near miss or incident location       Date of Incident:

     DD / MM / YYYY

Part 2. Incident Description Complete each section relevant to the incidentPlease attach photographs, timelines and diagrams of where the incident occurred and equipment being used if appropriate.

2.a General Incident DetailsPlease provide details of what occurred including what the involved person was doing immediately prior to the incident and any tools or equipment in use:(please provide attachments if more space is required)     

What time did the incident occur?       AM / PM SPECIFIC LOCATION :      

Was the lighting adequate? Yes No Did the incident occur: On Steps/Stairs

Was the area clean and tidy? Yes No Indoors On a Footpath - Ascending

Was Personal Protective Equipment (PPE) required for the task? Yes No Outdoors On a Walkway - Descending

If so, was the person correctly wearing the PPE? Yes No Comments:      

2.b Did the incident involve a Slip, Trip or Fall? Yes No (if no, proceed to next section)Were they carrying anything at the time? Yes No TYPE OF SURFACE:

SHOES WORN: Sneakers None Dry Wet Torn

Open Sandals High Heels Carpet Cement Gravel

Closed Boots Steel Capped Tile Road Grass

WAS THE PERSON: Walking Running Sand Rocks Damaged

Turning a corner Jumping Any other relevant information?      

DID THEY FALL ON THEIR: Front Side

Hands/Knees Back

2.c Did the incident involve a Manual Task? Yes No (if no, proceed to next section)Were the items within easy reach? Yes No DID THE ACTION INVOLVE:

Was ergonomic equipment used? Yes No Bending Carrying Kneeling

Was the equipment being used correctly? Yes No Pulling Reaching Twisting

Was the task repetitive or forceful? Yes No Catching Crouching Lifting

Distance Item Carried:      Item Weight:      Item Height:      Pushing Sitting Lowering

Any other relevant information?      

2.d Did the incident involve Equipment or Plant? Yes No (if no, proceed to next section)

What was the equipment or plant being used?       Was the appropriate safety equipment being used? Yes No

Was the equipment in good condition?(consider maintenance records)

Yes No Were the Standard Operating procedures being followed? Yes No

Any other relevant information?      

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HRSC Office Use OnlyIncident Number ________________Injury Number ________________

2.e Did the incident involve Chemicals? Yes No (if no, proceed to next section)Was a Safety Data Sheet available? (if yes please attach)

Yes No Was a Risk Assessment undertaken? if yes please attach) Yes No

Any other relevant information?      

2.f Did the incident involve Electricity? Yes No (if no, proceed to next section)Was the equipment tested and tagged in accordance with ECU’s Electrical Safety Policy?

Yes No Was there a Work Instruction for the work being undertaken and it so was it being followed?

Yes No

Were RCDs in use and properly maintained? Yes No Was the injured person encouraged to seek immediate medical advice? Yes No

Any other relevant information?      

2.g Other contributing factors to consider (tick all those that apply)

Environment – workplace/task design Environmental conditions (e.g. weather, lighting, ventilation, temperature)

Failure to follow work procedures Inadequate Supervision

Improper use/storage of materials Inadequate training

Inadequate equipment function Lack of experience in task/not competent

Inadequate equipment maintenance Poor/lack of suitable equipment

Inadequate safety procedures Untidy work area

Inadequate space Personal factors (e.g. stress, fatigue, pre-existing medical condition)

Other:      

2.h Key cause(s) of the incidentPlease outline the key causes of the incident and include any additional comments or observations(please provide attachments if more space is required)     

Part 3. Preventative action to address identified causesPlease refer to the Guidelines for Accident Investigation available from the Human Resources Services Centre intranet site

Where required, has the identified hazard been reported to the Maintenance Call Centre? Yes No

What is the Hazard Report Number (QFM Report Number)?      

Has the hazard been reported anywhere else?      

Please outline the action to be taken to prevent a future occurrence Consider the hierarchy of controls which outlines the most effective to the least effective method of controls

Risk Control Options Action to be taken Person Responsible

Date to be completed

Most effective

Least effective

Elimination (e.g. remove)                  

Substitution (e.g. alternate)

                 

Engineering/Isolation(e.g. guarding)

                 

Administration (e.g. training, standard operating procedures)

                 

Personal Protective Equipment (e.g. safety glasses, gloves)

                 

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Part 4. Sign Off

           DD / MM / YYYY

Person Injured / involved: Signature: Date:

           DD / MM / YYYY

Elected H&S Representative: Signature: Date:

           DD / MM / YYYY

Line Manager: Signature: Date:

           DD / MM / YYYY

Dean / Director: Signature:Date:

Part 5. Record KeepingUpdating the Hazard Risk RegisterFor more information on how your Faculty or Service Centre Hazard Risk Register can be updated, contact the Chair of your Local Work Health & Safety Committee

Have hazards identified as contributing to this incident been included in the area’s Hazard Risk Register?  If not, please review and add to the register.

Yes No

Incident Investigation Form Submission Completed and Signed copy to be provided within 5 working days to:

Line Manager

Elected Safety and Health Representative

Safety and Employment Relations, Human Resources Services Centre (Building 1, Joondalup Campus or email osh@ecu.edu.au)

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