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 icon3. To create a corrective action click on the paperclip icon then "Action", provide a description, assign to a member, set priority and due date4. Complete audit by providing digital signature5. Share your report by exporting as PDF, Word, Excel or Web Link
Personal and Incident Details
Date of Birth
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?
Date and Time of treatment
Time lost due to injury?
How many hours/days?
How did the injury happen?
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?
Equipment in good condition?
Date of last service of equipment
Appropriate safety equipment used?
Housekeeping issues contributed?
Type of shoes worn
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?
Weight of object
Distance carried/position of object moved from/to
Height of load
For the WHS Manager
Comments and Observation
Supervisor or WHS Manager Notification
Please note that this checklist template is a hypothetical 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.
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