INCIDENT INVESTIGATION REPORT

Project code

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Project details

Person(s) discovering

Person attending

Person investigating

Parties notified

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Incident date

Worksafe notifiable?

Death

A person needing medical treatment within 48 hours of being exposed to a substance

A person needing immediate treatment as an in-patient at a hospital

A person needing immediate medical treatment for one of the following injuries: amputation, serious head injury or serious eye injury, removal of skin, electric shock, spinal injury, loss of a bodily function, serious lacerations.

An employee or an independent contractor or a contractor’s employee has received a confirmed COVID-19 diagnosis and has attended the workplace during the infectious period.

Registered or licensed plant collapsing, overturning, falling or malfunctioning

Collapse or failure of an excavation, or shoring supporting an excavation

Collapse of a building structure (or partial collapse)

Implosion, explosion, or fire

Escape, spillage or leakage of any substance

Plant or objects falling from high places

N/A

Reported notifiable incident?

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Incident description

Type of injury

Intercranial injury (brain e.g. concussion)

Fracture (e.g. broken bone or spinal)

Traumatic amputation (e.g. loss of body part)

Laceration (e.g. puncture or cut)

Superficial wound (e.g. blister or splinter)

Burn (e.g. electrical, chemical)

Traumatic joint or muscle injury (e.g. sprain or dislocation)

Other condition/ disorder

Mental disorder (e.g. PTSD or psychotic episode)

Digestive system related (e.g. hernia or ulcer)

Nervous system related (e.g. epilepsy)

Respiratory system related (e.g. asthma)

Circulatory system related (e.g. heart attack or stroke)

Infection or parasite (including Covid19)

Name of person affected (injured)

DOB of person affected

Affected person mobile no.

Injured person relationship to project

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Reference to SWMS

Was the affected person conducting work in-line with a SWMS requirement? Provide reference

Activity at the time of injury

Exact location where injury occured

Body location of injury

Treatment provided at the time of incident

Referred for further treatment

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Witness name

Witness contact details

Emergency response as a result of incident?

Was the project-specific ECIMP followed?

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Other (immediate) response actions

Risk/hazard register update as a result of incident?

Provide reference to project specific HIRAC is available

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Request corrective (or preventative actions)?

(log a CPAR)

Evidence attachments

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