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Hazard/Incident Report Form 2019

This 3-part hazard/incident report form collects details about a reported hazard or incident. Part A collects information about the person reporting and basic incident details. Part B is for injury incidents and collects injury details like treatment received. Part C analyzes contributing factors, assigns a risk level, and outlines corrective actions needed with responsible parties and completion dates. The full report is then entered into the university's SafetyNet system.

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126 views3 pages

Hazard/Incident Report Form 2019

This 3-part hazard/incident report form collects details about a reported hazard or incident. Part A collects information about the person reporting and basic incident details. Part B is for injury incidents and collects injury details like treatment received. Part C analyzes contributing factors, assigns a risk level, and outlines corrective actions needed with responsible parties and completion dates. The full report is then entered into the university's SafetyNet system.

Uploaded by

geoanburaja
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

WHS UNIT

HAZARD / INCIDENT REPORT FORM


Part A – Form Details
Person Reporting The Incident Confidential
Person Type: Casual Contractor Employee Part-time Student P/G Student U/G Visitor
First name: Surname:
Email: Job Title:
Faculty/Division:
Unit:
Report to be Sent to
Supervisor:

Additional Supervisor(s):

Send Report Externally: Email 1: Email 2:


Incident Details
Incident Type: Incident – With Injury Incident – Without Injury Hazard Near Miss
Description of Incident/Hazard:

Date of Incident/Hazard: Time of Incident: Date Reported:


Reported To:
Location of Incident/Hazard: Building: Room:
Specific Location:

Part B – Injury Details: Only complete for ‘Incident – With Injury’. Otherwise proceed directly to Part C.

Injured Person
Person Type: Casual Contractor Employee Part-time Student P/G Student U/G Visitor
First name: Surname:
Email: Phone:
Level of Treatment:
Report only First Aid Medical Treatment Intend to Seek Medical Treatment Lost Time Injury
Name of First Aider or Treatment Provider:

Nature of Injury: Cut Bruising Bite/Sting Burn Crush Dislocation


Other
Body Location:
Mechanism:
Agency:
Description of Illness/Injury:

HRD-WHS-FRM-582.2 Hazard/Incident Report Form 2019 February Page 1 of 3


Specific task being performed at time of Incident/Injury:

Description of Treatment Provided:

Name of UOW First Aider:


Name of Treatment Provider: Name: Phone:

Part C: Corrective Actions


Contributing Factors
Details:
Lack of or inadequate plant/equipment

Lack of or inadequate procedures/instructions

Lack of or inadequate training

Lack of or inadequate management/supervision

Inappropriate or inadequate work environment

Inappropriate actions and/or behaviour

Lack of or inadequate management system

Other

Cause of Incident/Hazard:
Risk Assessment
High
Consequence Minor Moderate Major Severe Medium
Likelihood Unlikely Possible Likely Almost Certain Low

NOTE: For ‘Medium’ or ‘High’ risk incidents, at least one corrective action must be completed.
Corrective Actions
Control Type: Elimination Substitution Isolation Engineering Administration PPE
Corrective Action/s Description:

HRD-WHS-FRM-582.2 Hazard/Incident Report Form 2019 February Page 2 of 3


Person Responsible:

Action/s completed: Yes No, target date for completion:


NOTE: Please ensure this report is entered into SafetyNet at the earliest convenience
[Link]

HRD-WHS-FRM-582.2 Hazard/Incident Report Form 2019 February Page 3 of 3

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