Incident / Injury / Hazard / Damage Report Form
This form is used to report all hazards, near misses, injuries, damages and NDIS incident reporting. It also acts as ILS injury register. The form requires identification of corrective and preventative actions taken by management to address the identified hazard.
Please complete within 24 hours of the Injury / Incident.
WHS - Any incident or injury that caused any medical treatment is to be reported to your State GM and the National WHS Manager -Teri Houseman (0412 363 496) NDIS - If it is a NDIS incident or concern, please contact Jo Loneragan (0414 868 182).
To be completed by person involved, supervisor, WHS Representative.
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What are you reporting?
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Hazard
Near Miss
Injury
Property Damage
NDIS incident or concern
Name
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Person filling in form.
State:
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ACT / NSW
QLD
SA
VIC
Subwork group:
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Administration
ATP / Service technician
Medical Installers
Showroom
Warehouse / Laundry
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Date hazard / incident occurred
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Month
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Day
Year
Date
Location
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Facility name or write external location.
Describe hazard / incident
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Immediate actions taken at the time
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Further corrective actions to implement
Picture
Upload a picture of hazard, incident or damage.
Browse Files
Cancel
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Signature
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Submit
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Injury / NDIS incident Information
Are you a:
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ILS Employee
Casual, Temporary, contracted employee
Client / Customer
Service Provider
Site visitor / external person
Injury Classification (only select 1)
Lost time injury - one day or more off work.
Restricted work injury - full hours but on medical restrictions.
Medically treated injury - Dr has prescribed or performed medical treatment.
First aid injury
NDIS Reportable / Concern
Injured persons full name:
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First Name
Last Name
Email Address
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example@example.com
Date of Birth
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Day
-
Month
Year
Date
Injured persons home address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender:
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Female
Male
Other
If you are a customer are you a:
NDIS Participant
Private customer
Not a customer
Department:
Position:
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Contact Number:
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-
Area Code
Phone Number
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Details of Injury / Near Miss / Hazard / Damage
Date and time of the injury:
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Day
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Month
Year
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Hour
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Minutes
AM
PM
AM/PM Option
Date on which the entry is made into the register
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-
Day
-
Month
Year
Date
Injury location information
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Full name and contact number for any witness (if any)
Select nature of the injury
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Allergy / Allergic reactions - Inc rash
Amputation
Bruise
Burn
Cut / Laceration / Puncture
Dislocation
Electric shock
Foreign Body
Fracture
Grazes, scratches, abrasions
Head Injury
Health Issue - e.g Respiratory
Hearing Loss
Heat Stress / exhaustion
Internal injury - e.g hernia
Loss of consciousness - Fainting, seizure
Muscluloskeletal injury - inc Sprains / Strains
Poisoning / toxic effects of substance
Psychosocial
Aggravation of previous injury or medical condition
Other
Select body part injured (Multiple selections may be required)
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Name of First Aider:
First Name
Last Name
First aid treatment:
Hazard category (tick one main category)
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Manual Handling
Slips, trips and falls
Plant, equipment & structures
Biological
Ergonomics / office
Working at height
Other Tools
Road transport
External Environment inc Animal / Insect or non ILS location
Hot/Cold environment or object
Working Alone / isolation
Electrical & other energy sources
Falling / flying object
Hazardous/Dangerous Substance
Vibration / noise
Psychosocial - e.g Stress
Personal / Company car
Not applicable
Other
Select one main cause (tick appropriate answers)
Lifting
Pushing
Pulling
Bending
Carrying
Twisting
Weight or size of the object
Tripping / Slipping
Stepping on / off / Falling
Striking Against
Struck By
Caught In
Absorption
Motor Vehicle
Inhalation
Needlestick
Ingestion
Stress - Phycological factor
Other
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Investigation & Preventative Action
This is an extremely important section as it identifies preventative action that will avoid recurrence or a similar injury / incident / hazard.
Potential cause of Injury
System - Procedures / SOP / training
System - Workload
System - Maintenance
System - Task
System - Monitoring
Equipment - Design
Equipment - Size / weight
Equipment - Maintenace
Equipment - Inadequate / not available
Equipment - Chemicals
Environment - Workplace design
Environment - Access
Environment - Housekeeping
Environment - Floor / surface
Environment - weather / temperature
Environment - External factor
People - Supervision
People - Training
People - Job competency
People - Behaviors e.g SOP not followed
People - PPE
Other
Describe how the injury occurred:
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IMMEDIATE ACTION taken - to control & prevent a recurrence of injury
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Potential further controls - to prevent a recurrence of injury
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Supporting Photos or documents
Browse Files
Cancel
of
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Report Prepared By:
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First Name
Last Name
Signature
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Injured worker signature
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Submit
Should be Empty: