INCIDENT/INJURY REPORT FORM

Please print clearly
Position:
Outcome:

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Employee
Near miss

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Volunteer
Injury

Contractor
Property damage

1. DETAILS OF PERSON INVOLVED
Name:

Phone: (H)

Address:

(W)

Sex:

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Male

Date of birth:
Position:
Experience in the job:

(years/months)

Start time:

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Work arrangement:

Casual

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Full-time

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am

Part-time

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pm

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Other

2. DETAILS OF INCIDENT
Date:

Time:

Location:
Describe what happened and how:

3. DETAILS OF WITNESSES
Name:

Phone: (H)

Address:

4. DETAILS OF INJURY
Nature of injury (eg burn, cut, sprain)
Cause of injury (eg fall, grabbed by person)
Location on body (eg back, left forearm)
Agency (eg lounge chair, another person, hot water)

5. TREATMENT ADMINISTERED
First Aid given
First Aider name:
Treatment:
Referred to:

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Yes

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No

(W)

Female

OHS MANAGEMENT CHECKLIST (ANNUAL REVIEW) FORM

Please print clearly

Yes No
OHS policies / plan
OHS policy developed (written)

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Policy includes responsibilities of managers and workers

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Policies and procedures reviewed regularly

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Workers aware of OHS policies and procedures

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OHS plan developed

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OHS plan reviewed regularly

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Responsible officer appointed

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OHS committee elected

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Health and safety representatives elected

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OHS discussed at staff meetings

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OHS discussed at contractor meetings

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All new employees receive OHS induction training

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Workers receive regular ongoing OHS training

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Managers/co-ordinators receive OHS training and updates

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Records kept of OHS training (aims, attendance, date, presenter)

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Pre-service checks of homes conducted

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Checks reviewed regularly

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Community venues checked pre-use (access etc)

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Offices inspected regularly

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System in place for reporting hazards
(eg hazard forms)

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Hazards reported by workers

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Consultation

OHS training

Managing hazards

Comments

OHS MANAGEMENT CHECKLIST (ANNUAL REVIEW) FORM

Yes No
Managing hazards [cont]
Processes in place to address:

• others

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Risk assessments carried out on hazards

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Hazards / reports followed up and controlled

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Controls reviewed for effectiveness

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Client needs considered when addressing hazards ❒

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OHS considered when purchasing new equipment (eg for office, vehicles)

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Form available for reporting incidents and injuries

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Workers (including contractors and volunteers) aware of the reporting procedure

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Incidents investigated and documented

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Procedure in place for claims management

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Process in place to manage rehabilitation and return to work following injury

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• manual handling
• isolated work
• slips, trips and falls
• staff security
• electrical hazards
• hazardous substances
• infection control
• pet aggression
• bathroom safety

Incident reporting / investigation

Injury management

Comments

INCIDENT/INJURY REPORT FORM

SECTIONS 6-9 MUST BE COMPLETED BY CO-ORDINATOR
6. DID THE INJURED PERSON STOP WORK?

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Yes

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No

If yes, state date:

Time:

Time lost (days)

Outcome:

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Treated by doctor
Returned to normal work

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Hospitalised
Alternative duties

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Workers compensation claim
Rehabilitation

7. INCIDENT INVESTIGATION (comments to include causal factors - add extra sheets if needed)

8. RISK ASSESSMENT
Likelihood of recurrence:
Severity of outcome:
Level of risk:

9. ACTIONS TO PREVENT RECURRENCE
Action

By whom

10. ACTIONS COMPLETED
Signed (Manager):

Title:
Date:

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Feedback to person involved

Date:

11. REVIEW COMMENTS
OHS committee / staff meeting:
Reviewed by Manager (signed):

Date:

Reviewed by HSR (signed):

Date:

By when

Date completed

CLIENT HOME OHS ASSESSMENT FORM
Please print clearly
Client name:

File Number:

Address:

Phone:

Person completing checklist:

Date:

Location: (draw map and attach if needed)

Parking:

Review date:
Location of door to enter:

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