Incident/Accident Report
ADMIN FORM 1
Incident Report No.
Date submitted:
PART 1: REPORTER DETAILS
First Name
Last Name
Phone Number
Email
Incident Type
Other Incident Type
Give a short description of incident.
Enter your Admin Code
Admin User Name
PART 5 - MANAGEMENT RESPONSE
Manager's Report
Date of Investigation
*
/
Day
/
Month
Year
Date
Date of Incident Occurrence:
*
/
Day
/
Month
Year
Date
Has a similar incident/near miss occurred previously?
*
Yes
No
Unknown
Was it a notifiable incident?
*
Yes
No
Unknown
Name of government/organisation notified:
*
Investigation Lead
First Name
*
Last Name
*
Position:
*
List all of the people that are involved in the investigation.
Include their Name, Title, Company and Role in the investigation.
Description of Event
Who was involved in the incident?
*
Employee/Worker
Participant
Participant representative
Volunteer
Visitor
Contractor
Member of Public
Other
What task was being performed at the time of the incident?
*
Summary of Incident
*
Briefly describe what happened at the time of the incident/near miss.
Are there any relevant photos?
Browse Files
Cancel
of
Controls immediately implemented:
*
Consider: Update on board report, WHS Issues, Added to Continuous Improvement Register, and Staff Training.
SECTION COLLAPSE - CONTRIBUTING FACTORS
What factors contributed to the incident?
Environment
Equipment/Materials
Work Systems
People
Other
Environment:
Noise
Lighting
Vibration
Damaged/unstable floor
Layout/design
Dust/fume
Slip/trip hazard
Other
Recommendation - Environment:
Person(s) responsible - Environment:
Due Date - Environment
/
Day
/
Month
Year
Date
Completion Date - Environment
/
Day
/
Month
Year
Date
Equipment/Materials
Wrong equipment for the job
Inadequate maintenance
Inadequate guarding
Equipment failure
Material/equipment too heavy/awkward
Other
Recommendation - Equipment:
Person(s) responsible - Equipment:
Due Date - Equipment
/
Day
/
Month
Year
Date
Completion Date - Equipment
/
Day
/
Month
Year
Date
Work Systems:
Hazard not identified
No/inadequate safe work procedure
Hazard not reported
No/inadequate risk assessment conducted
No/inadequate controls implemented
Inadequate training/supervision
Other
Recommendation - Work Systems:
Person(s) responsible - Work Systems:
Due Date - Work Systems
/
Day
/
Month
Year
Date
Completion Date - Work Systems
/
Day
/
Month
Year
Date
People:
Procedure not followed/no procedure exists
Fatigue
Change of routine
Lack of Communication
Drugs/Alcohol
Time/work pressures
Distraction/personal issues/stress
Other
Recommendation - People:
Person(s) responsible - People:
Due Date - People
/
Day
/
Month
Year
Date
Completion Date - People
/
Day
/
Month
Year
Date
Recommendation - Other:
Person(s) responsible - Other:
Due Date - Other
/
Day
/
Month
Year
Date
Completion Date - Other
/
Day
/
Month
Year
Date
SECTION END - CONTRIBUTING FACTORS
What was the outcome following the incident?
*
Consider: Update on board report, WHS Issues, Added to Continuous Improvement Register, and Staff Training.
Any follow-up actions already completed?
*
Risk of same/similar incident recurrence
(Y axis = likelihood. X axis = impact)
Risk - Likelihood
*
Never
Rare
Unlikely
Possible
Likely
Almost Certain
Certain
Risk - Impact
*
None
Minimal
Minor
Moderate
Significant
Severe
Catastrophic
Risk Score (%)
Manager's Signature:
Save
Submit
Enter your Admin Code
Admin User Name (2)
End Office use 1
Notifiable Incident
Is this a Notifiable Incident?
*
Yes
No
Date of report to NDIS
-
Day
-
Month
Year
Date
Has a 5-day report been submitted?
*
Yes
No
Date 5-day report submitted:
-
Day
-
Month
Year
Date
Final Action
Was the follow up action completed?
Yes
No
Partial
Was the issue fixed?
Yes
No
Ongoing
Is Continuous improvement required?
Yes
No
Date entered into Continuous Improvement Register
-
Day
-
Month
Year
Date
Was the incident withdrawn?
Yes
No
Date withdrawn:
/
Day
/
Month
Year
Date
Action competed by Whom
First Name
*
Last Name
*
Date Completed:
-
Day
-
Month
Year
Date
Signature:
Save
Submit
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