Work Health and Safety
Investigation Form
PART A: INCIDENT/HAZARD DETAILS
1. Incident Identification
Incident/Hazard Number
Other identifier(s)
2. Task and Location
Date and Time
Incident
Workplace
Location
3. Organisational Unit details
Organisational Unit (OU)
OU Manager
OU Contact
4. Contractor Details (if applicable)
Contractor
Contract business
Contractor Contact
5. Person(s) involved
Name
Position/Title
Injured
worker
Supervisor
Witness
1.
2.
3.
4.
6. Injury/Damage Event
Injury sustained
Injury severity and treatment
Property damage or harm
Assessed risk (the potential for injury or
damage)
Consequence X Likelihood = Risk
7. Immediate Action taken
Immediate action taken to prevent
further injury, harm or loss
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Work Health and Safety
Investigation Form
8. Initial Report
Initially reported by:
Reported to:
How and when was the report made?
Then reported by:
Reported to:
How and when was the report made?
9. Notification (if required)
Description
Notification (1)
Reported by:
When was the report made?
Identifier/contact
Notification(2)
Reported by:
When was the report made?
Identifier/contact
Notification(3)
Reported by:
When was the report made?
Identifier/contact
Post event
Reporting
Follow up
10. Sequence of Events
Background
Pre-event
Injury event
11. Attachments
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Work Health and Safety
Investigation Form
PART B: INVESTIGATION
1. Supervision
What supervision was provided to
the person for the task?
What supervision was required for
the task?
2. Risk Management
Was a risk assessment undertaken
before commencing this task?(if NO
please provide an explanation why)
What hazards and risk controls were
identified for this task?
Does a Regulation, Code of Practice
or other Standard apply to this task?
Which University Minimum
Standards and procedures apply to
this task?
3. Induction and Training
Had the person(s) involved received
induction to the area?
What training had the person(s)
received for the task?
4. Plant or equipment
What plant or equipment was being
used?
Was the plant suitable for the task?
Was the plant used according to a
Safe Work Procedure?
Was the plant in good working
order?
Were the hazards of the plant
assessed in the local Hazard& Risk
Register?
Was the maintenance schedule of
the plant described in the local
Testing, Inspection & Monitoring
Program?
5. Emergency Response
Was an emergency response
required and if so which services
were contacted?
Was notification required and if so
was this completed in a timely
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Work Health and Safety
Investigation Form
manner?
6. Contributing factors
Determine both the immediate and the contributing/underlying factors of the incident or damage
event using the Incident Cause Analysis Method (ICAM) or a similar root cause analysis process.
Immediate cause
Underlying causes
7. Investigation
8. Investigation Report
Investigation report prepared by:
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Work Health and Safety
Investigation Form
PART C: CORRECTIVE ACTION PLAN
List the recommendations to address both the immediate and underlying causes (applying the
Hierarchy of Control of Elimination, Substitution, Engineering, Administrative, and Personal
Protective Equipment). Include both short and long term measures to prevent this incident from
occurring in the future.
Control Measures
Person
Date for
Status
responsible for Action to be
action
completed
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