Hazard / Incident Report
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DRAFT
FINAL
Site & Reporting Details
Site
*
CQLX
CRLX
CTLX
CVLX
HRLX
IRLX
NVLX
SELX
TRLX
WVLX
Corporate
Operations & Maintenance or Ancillary Service Incident
Operations & Maintenance
Ancillary Services
Not Applicable
Date
*
-
Day
-
Month
Year
Date
Time
*
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Hour
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Minutes
AM
PM
AM/PM Option
Exact location of Hazard / Incident on site
*
Person Submitting Report
*
Full Name
Company
*
Status
*
Please Select
RLX Employee
Livestock Agent
Transport Driver
Trade Contractor
Labour Hire
Visitor
Who was this Hazard / Incident reported to
*
If not verbally reported, type N/A
Type of Report
What type of Report is this?
Hazard
Incident
Hazard Report
Describe the Hazard
*
What type of Hazard is it?
*
Animal other than livestock
Biological
Buildings and Structures
Confined Space
Contact with Object
Driving/Traffic
Electricity
Environmental
Ergonomic
Extreme Temperatures
Fire Safety
Gravity (Slip\Trips\Falls)
Hazardous Chemicals
Hygiene
Livestock Interaction
Machinery & Equipment
Manual Handling
Noise
Procedural
Psycho-social
Radiation
Signage
Vibration
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What immediate actions have been taken to make safe?
*
If nothing then write 'Nil'.
Upload Photo of completed action
*
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End Hazard Report
Incident Report
Person involved in incident or Injured Details
Name of injured or person involved in the incident
*
Position / Role / Company
*
Person Category
Employee
Labour Hire
Transport Driver
Contractor
Agent Employee
Buyer
Vendor
Visitor
Not Applicable
Gender
Male
Female
No Person Involved
Date of Birth
-
Day
-
Month
Year
Date
Incident Details
What type of incident occurred?
*
Injury/Illness
Environmental
Near Miss
Property Damage
Security
Animal Related
Escaped Animal
What type of injury/illness occurred?
*
Commuting Injury
Fatality
First Aid Injury
Lost Time Injury
Medical Treatment Injury
Non Work Related Injury
Aggravation of an Existing Injury
Is the near miss a high potential near miss based on the following definition below? "The near miss had the potential to result in medical treatment or lost time"
*
Yes
No
Activity being undertaken
*
Describe Incident in detail
*
End Incident Report
Injury Report
Injury Details
Side of Body Injured
*
Left
Right
Not Applicable
Undetermined
Body Part Injured
*
Ankle
Arm
Back-lower
Back-upper
Eye
Ear
Elbow
Face
Fingers
Foot
Hand
Head (other than eye, ear and face)
Hip
Internal Organs
Knee
Leg
Neck
Multiple Locations
Psychological
Rib
Shoulder
Teeth
Toes
Trunk (other than back)
Wrist
Nature of Injury
*
Abrasion
Aggravation of pre-existing condition
Burn - hot/cold
Electrical burn
Chemical burn
Chipped teeth
Contusion with intact skin
Superficial injury
Crush injury
Contusion/bruising
Needle stick or puncture wound
Dislocation
Electric shock
Foreign body in eye, ear or nose
Fracture
Internal injury of chest, abdomen and pelvis
Intracranial injury, including concussion
Laceration/Open wound
Pain
Poisoning/toxic effects
Heat stress/heat stroke
Effects of weather, air movement
Sprain/strain-low loading
Sprain/strain-high loading
Traumatic amputation
Disease or illness
Multiple injuries
Unspecified injuries
Other specified injuries
Psychological Stress
The type of hurt or harm that occurred to the worker
Mechanism of Injury
*
Caught Between Objects
Falls from Height
Falls from same level
Stepping/Kneeling
Hitting stationery objects
Hitting moving objects
Hit by falling objects
Hit by an animal
Hit by moving object
Trapped by moving machinery
Trapped between moving objects
Exposure to single sudden sound
Long term exposure to sound
Repetitive movement
Contact with hot objects
Contact with cold objects
Environmental heat
Environmental cold
Single contact with chemical
Long term contact with chemical
Contact with electricity
Exposure to mechanical vibration
Insect/reptile bites and stings
Exposure to biological factors
Exposure to traumatic event
Exposure to violence
Work pressure
Exposure to mental stress
Exposure to psychological factors
Extreme weather conditions
Manual tasks
Muscular stress from lifting
Muscular stress from handling objects
Muscular stress from body position
Outdoor environment
Slips/trips
Vehicle accident
Medical Condition
Factors outside of the workplace
Bullying/Harassment
The process that best describes the circumstances in which the incident or injury occurred
Agency of Injury
*
Chemicals interaction
Materials/products interaction
Human Agencies
Biological Agencies
Indoor environment
Lifting
Animals/Insects/reptiles
Livestock
Machinery and fixed plant
Mobile Plant
Non-powered equipment, tools, appliances
Powered equipment, tools, appliances
Outdoor Environment - weather/solar/temp
Indoor Environment - temp/lighting/ventilation
Uneven ground surface
Vehicle transport
Factors outside of the workplace
The object, substance or circumstance directly involved in the cause of the incident / injury
Injured Person Status
*
Unfit for Work
Fully Fit
Partially fit, restricted duties
NA
Initial Onsite Treatment Provided
*
Time Lost
*
Total Number of days lost (not including day of injury). 'NA' if less than one full day.
End Injury Report
Action Report
What factors were involved in or led to the incident?
*
Details of any immediate actions taken
*
Action to prevent or reduce likelihood of incident recurring
*
Action assigned to (email address)
*
example@example.com
Action - Due Date
*
-
Day
-
Month
Year
Date
Has the action been completed yet?
*
Please Select
Yes
No
If 'No' is selected, you will need to go back it to close the action when it is completed
Date Action Closed
*
-
Day
-
Month
Year
Date
Upload Photo of completed action
*
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End Action Report
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