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Incident Report Checklist

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Incident Report Checklist

Audit

Instructions

1. Complete the report by providing relevant details of the injured person, incident and description of root cause 2. Add any photos and notes by clicking on the paperclip icon 3. To create a corrective action click on the paperclip icon then "Action", provide a description, assign to a member, set priority and due date 4. Complete audit by providing digital signature 5. Share your report by exporting as PDF, Word, Excel or Web Link

Personal and Incident Details

Full Name

Date of Birth

Sex

Occupation

Contact number

Home address

Email address

Injury Details

Type of injury or disease (e.g burn)

Part/s of the body affected

Mark areas of body affected

Date and Time of symptoms

Was medical treatment given?

Treatment provided

Provider

Date and Time of treatment

Time lost due to injury?

How many hours/days?

How did the injury happen?

Investigation

How long had you been working prior to the incident?

How long had you been working on this task?

Is this task part of your normal duties?

Have you been trained for this task?

What were you doing in the time prior to the incident?

Are there any other factors involved (e.g management, work environment, equipment) involved?

What do you think could have been done to prevent this from occuring?

Other comments or observations

What sort of injury occurred?

Type of injury?

Safe Work Method Statements followed?

Equipments/objects/insects involved?

Equipment in good condition?

Date of last service of equipment

Appropriate safety equipment used?

Lighting adequate?

Housekeeping issues contributed?

Surface type

Type of shoes worn

Workload excessive?

Workload boring and repetitive?

Is it a slip or trip?

Height of fall

Were you -

If stairs -

Did you fall on your -

What were you carrying (if anything) at that time?

Does it involve manual handling?

Were your items within easy reach?

Ergonomic equipment available?

Was the equipment being used correctly?

Repititive and forceful movements used?

Action involved

Weight of object

Distance carried/position of object moved from/to

Height of load

For the WHS Manager

Comments and Observation

Recommendation

Person assigned

Target Date

Supervisor or WHS Manager Notification

Supervisor

WHS Manager

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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.