Whsmp · OPW16/0021

                                                                                                                                                    Incident/Injury /Hazard Report Form
                                                                                                                                                                                                                          HB-HSEQ-F-027-B
                                                                                                                                                                                                                               Version: 11


      Medical Treatment                                        NIL                                                                                     Ambulance
               Required                                        First Aid ONLY – (NO DR REQUIRED)                                                       Admitted to Hospital (STAY OVER NIGHT AT HOSPITAL)
                                                               Doctor ONLY – (MEDICAL CENTRE)
            On site First Aid                         Clean wound                                         Dressing                                                  Bandage
                 Treatment                            Remove foreign body                                 Place in recovery position                                Support and keep calm
              Administered                              Pressure bandage                                  Did not move until help arrived                           Splint to leg or arm
                                                       Other:

Describe the sequence of events in relation to the Incident / Hazard / Impact (attach additional documentation if required)




What factors do you believe contributed to the: Incident - Hazard – Injury – Illness – Environmental Impact or System Failure




EQUIPMENT DAMAGE

            Did any property damage occur:                                           Yes                                 No                        Estimated Cost:       $

       IF YES, Describe Type of Equipment                                                                                                                                      Owner:

ADDITIONAL FACTORS

                                                                 Occupation of injured:


                                                 Who was supervising the work?
                         Ticket / Competency for the works undertaken
                                           (List the VOC/Licence type)
                             Does the worker have relevant SWMS signed                                                                                         Yes                             No
             Other (specify):

WITNESS DETAILS / OTHER PERSONS INVOLVED:                                                                                                    WITNESS STATEMENTS COMPLETED ON HB-HSEQ-F-027-C
     Name                                                                                                            Phone                                                                Statement                 Yes                  No
     Name                                                                                                            Phone                                                                Statement                  Yes                  No
                                Were photgraphs taken:                                        Yes                   No                             By Whom:

                                           Was the scene disturbed in any way after the incident?                                                    Yes            No
       If YES, How?


CORRECTIVE & PREVENTATIVE ACTIONS (What do we need to do to fix the immediate issue and stop it from happening again?)
                                                                                                                                                              Date Completed                                       Signed
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2.    ..........................................................................................................................................            ...........................         ...................................................
3.    ..........................................................................................................................................
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4.    ..........................................................................................................................................
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ALL fields are to be completed prior to closing out the incident.                                                                                                                                                             Page 2 of 3