SA GENEALOGICAL & HERALDRY SOCIETY ACCIDENT/INCIDENT REPORT and INVESTIGATION FORM
Date report is being made: PART A: This form is to be used for ALL accidents, or near misses, whether an injury occurred or not ACCIDENT / INCIDENT REPORT FORM TO BE COMPLETED BY PERSON INVOLVED (or by supervisor or if person is incapacitated then by nearest relative) Please complete within 24 hours of the accident. If the accident caused, or could have caused, serious injury or property damage, please contact SAGHS on 08 8272 4222 immediately.
1: INFORMATION ABOUT THE PERSON MAKING THE REPORT (please print)
Title Dr Ms Status: Employee Contractor Occupation: Volunteer Visitor YES NO Member Other (describe) Contact telephone number Gender: Male Female Mr Mrs Surname or Family name Given Name Date of Birth
Are you currently employed? Name of employer: Address: Will you require time off work? What type of event is this? Where did it occur?
If yes, please provide employer details
Post Code: YES Accident NO Incident days Near Miss weeks
unknown
Approximately how long will you be off work? Medical YES Date Reported NO
Have you already reported the accident / incident / near miss? If YES, who did you report it to? Name
2: WHAT PART OF THE BODY WAS AFFECTED (tick appropriate answers)
Head
Eye Ear Nose Mouth Teeth Face Skull
Trunk
Neck Hip Chest Stomach Groin Back Multiple
Internal
Heart Lungs Systemic
Arm
Left Right Shoulder Upper Arm Elbow Forearm Wrist
Hand
Left Right Thumb Fingers
Leg
Left Right Knee Lower Leg Ankle Thigh
Foot
Left Right Great Toe Other Toes
Accident / Incident Report & Investigation Form Version 1: 2004 Date Printed: 6/04/2013
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SA GENEALOGICAL & HERALDRY SOCIETY ACCIDENT/INCIDENT REPORT and INVESTIGATION FORM
3: NATURE OF INJURY (tick appropriate answers)
Abrasion Puncture Heart Attack Sprain Burn Traumatic Shock Electric Shock Psychosocial Chemical
Bruise Laceration Hearing Loss Strain Scald Fracture Amputation Foreign Body Hernia Rash Concussion Bite Minor Cuts Allergy Aggravation of previous injury or medical condition, or other injury not already specified. (describe)
4: HOW DID THE ACCIDENT/INCIDENT OCCUR (tick appropriate answers)
Striking Against Struck By Caught In Stepping On Other: Describe Stumbling Slipping Tripping Falling Lifting Bending Twisting Stress Pushing Pulling Jumping Motor Vehicle Ingestion Absorption Inhalation
5: AGENCY OF INJURY (tick)
Vehicle Power tools Animal/Insect Biological agent Objects Buildings Furniture Heat Stress Chemicals Ionising radiation Mobile Plant Other tools Materials Equipment Structures Surfaces Sunburn Stress
Signed: PART B:
Date:
INVESTIGATION FORM TO BE COMPLETED BY THE SUPERVISOR AND/OR DELEGATED OFFICER WITHIN 48 HRS OF NOTIFICATION
IMPORTANT: This part of the process is designed to prevent recurrences
1: PROBABLE CAUSE/S OF ACCIDENT / INCIDENT (tick appropriate answers)
Inadequate Instruction Inadequate Workspace Assistance Unavailable Other (Describe) Fault Of Plant Or Equipment Equipment Unavailable Lack Of Attention Poor Storage Poor Access Incorrect Method Weather Terrain Work Practices
2: DESCRIBE THE ACCIDENT / INCIDENT
3: RATE THE POTENTIAL SEVERITY OF THE ACCIDENT / INCIDENT
(e.g. what could have happened?) Low
(eg first aid treatment)
Moderate
(eg medical attention)
High
(eg ambulance or other emergency services)
Severe
(eg death or severe disablement)
Accident / Incident Report & Investigation Form Version 1: 2004 Date Printed: 6/04/2013
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SA GENEALOGICAL & HERALDRY SOCIETY ACCIDENT/INCIDENT REPORT and INVESTIGATION FORM
4: PREVENTION OF ACCIDENT/INCIDENT RECURRENCE
Describe what action is planned or has been taken to prevent a recurrence of the accident/ incident, based on the key contributing factors (Please print) Immediate action taken Suggested long term action IS TRAINING REQUIRED?
Induction Task specific Area specific YES YES YES NO NO NO
REHABILITATION
Is required Is not required Unknown as yet Time Off Work Required.
5: ADMINISTRATION
Investigation undertaken by supervisor or delegated officer Print name: Signature: A copy of this report must be provided to the person making the report. The original must be retained by SAGHS copy provided to person making report Date Date investigation completed:
Accident / Incident Report & Investigation Form Version 1: 2004 Date Printed: 6/04/2013
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