Human Resources Services Centre
Safety and Employment Relations
HRSC Office Use Only
Incident Investigation Form
To be completed by the Supervisor/Manager (All fields mandatory)
Incident Number
________________
Injury Number
________________
Please refer to the Incident Reporting and Investigation Guideline to assist with the completion of this form.
All investigations must be undertaken by the Supervisor/Manager in consultation with the Elected Health and Safety Representative.
Part 1. Incident Details An online incident notification form should have been completed prior to this form.
Name of Person Injured or Involved in the
incident/near miss or incident location
Date of Incident:
DD / MM / YYYY
Part 2. Incident Description Complete each section relevant to the incident
Please attach photographs, timelines and diagrams of where the incident occurred and equipment being used if appropriate.
2.a General Incident Details
Please provide details of what the involved person was doing immediately prior to the incident and any tools or equipment in use:
(please provide attachments if more space is required)
What time did the incident occur?
AM / PM
SPECIFIC LOCATION :
Was the lighting adequate?
Yes
No
Was the area clean and tidy?
Yes
No
Indoors
On a Footpath
- Ascending
Yes
No
Outdoors
On a Walkway
- Descending
Yes
No
Was Personal Protective Equipment
(PPE) required for the task?
If so, was the person correctly wearing
the PPE?
Did the incident occur:
Comments:
2.b Did the incident involve a Slip, Trip or Fall? Yes
Were they carrying anything at the time?
SHOES WORN:
Sneakers
Open
Closed
WAS THE PERSON:
Yes
On Steps/Stairs
No
No
(if no, proceed to next section)
TYPE OF SURFACE:
None
Dry
Wet
Torn
Sandals
High Heels
Carpet
Cement
Gravel
Boots
Steel Capped
Tile
Road
Grass
Walking
Running
Sand
Rocks
Damaged
Turning a corner
DID THEY FALL ON THEIR:
Any other relevant information?
Jumping
Front
Side
Hands/Knees
Back
2.c Did the incident involve a Manual Task?
Yes
No
(if no, proceed to next section)
Were the items within easy reach?
Yes
No
Was ergonomic equipment used?
Yes
No
Bending
Carrying
Kneeling
Was the equipment being used correctly?
Yes
No
Pulling
Reaching
Twisting
Was the task repetitive or forceful?
Yes
No
Catching
Crouching
Lifting
Item Height:
Pushing
Sitting
Lowering
Distance Item Carried:
Item Weight:
DID THE ACTION INVOLVE:
Any other relevant information?
2.d Did the incident involve Equipment or Plant? Yes
What was the equipment or plant being used?
Was the equipment in good condition?
(consider maintenance records)
Any other relevant information?
Yes
No
Incident Investigation Form
All printed copies are uncontrolled.
M:\Human Resource Services\03 OSH\Forms and Templates
No
(if no, proceed to next section)
Was the appropriate safety
equipment being used?
Yes
No
Were the Standard Operating
procedures being followed?
Yes
No
Updated 2 March 2015
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Human Resources Services Centre
Safety and Employment Relations
2.e Did the incident involve Chemicals?
Was a Safety Data Sheet available?
(if yes please attach)
Any other relevant information?
Yes
No
Yes
Yes
No
Yes
No
(if no, proceed to next section)
Was a Risk Assessment undertaken? if
yes please attach)
No
2.f Did the incident involve Electricity?
Was the equipment tested and tagged in
accordance with ECU’s Electrical Safety
Policy?
Were RCDs in use and properly maintained?
No
Yes
Yes
No
(if no, proceed to next section)
Was there a Work Instruction for the work
being undertaken and it so was it being
followed?
Was the injured person encouraged to
seek immediate medical advice?
Yes
No
Yes
No
Any other relevant information?
2.g Other contributing factors to consider
(tick all those that apply)
Environment – workplace/task design
Environmental conditions (e.g. weather, lighting, ventilation, temperature)
Failure to follow work procedures
Inadequate Supervision
Improper use/storage of materials
Inadequate training
Inadequate equipment function
Lack of experience in task/not competent
Inadequate equipment maintenance
Poor/lack of suitable equipment
Inadequate safety procedures
Untidy work area
Inadequate space
Personal factors (e.g. stress, fatigue, pre-existing medical condition)
Other:
2.h Key cause(s) of the incident
Please outline the key causes of the incident and include any additional comments or observations
(please provide attachments if more space is required)
Part 3. Preventative action to address identified causes
Please refer to the Guidelines for Accident Investigation available from the Human Resources Services Centre intranet site
Where required, has the identified hazard been reported to the Maintenance Call Centre?
Yes
No
What is the Hazard Report Number (QFM Report Number)?
Has the hazard been reported anywhere else?
Please outline the action to be taken to prevent a future occurrence
Consider the hierarchy of controls which outlines the most effective to the least effective method of controls
Risk Control Options
Action to be taken
Person
Responsible
Date to be
completed
Elimination
Most
effective
(e.g. remove)
Substitution
(e.g. alternate)
Engineering/
Isolation
(e.g. guarding)
Administration
Least
effective
(e.g. training, standard
operating procedures)
Personal Protective
Equipment
(e.g. safety glasses, gloves)
Incident Investigation Form
All printed copies are uncontrolled.
M:\Human Resource Services\03 OSH\Forms and Templates
Updated 2 March 2015
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Human Resources Services Centre
Safety and Employment Relations
Part 4. Sign Off
DD / MM / YYYY
Person Injured / involved name:
Signature:
Date:
Elected H&S Representative:
Signature:
Date:
DD / MM / YYYY
DD / MM / YYYY
Line Manager:
Signature:
Date:
DD / MM / YYYY
Head of School / Manager name:
Signature:
Date:
Executive Dean / Director name:
Signature:
Date:
DD / MM / YYYY
Part 5. Record Keeping
Updating the Hazard Risk Register
For more information on how your Faculty or Service Centre Hazard Risk Register can be updated, contact the Chair of your Local Work Health & Safety Committee
Have hazards identified as contributing to this incident been included in the area’s Hazard Risk Register?
If not, please review and add to the register.
Yes
No
Incident Investigation Form Submission
Completed and Signed copy to be provided within 5 working days to:
Line Manager
Elected Safety and Health Representative
Safety and Employment Relations, Human Resources Services Centre (Building 1, Joondalup Campus or email osh@ecu.edu.au)
Incident Investigation Form
All printed copies are uncontrolled.
M:\Human Resource Services\03 OSH\Forms and Templates
Updated 2 March 2015
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