OF0027 – Incident Investigation and Actions Form

OF0027 – Incident Investigation and Actions Form

Amendment Record

PART 1 - INVESTIGATION CHECKLIST

Identification of Equipment/ Object/ Insect Involved

Complete if incident was a slip, trip or fall

If the incident involved Chemicals

If the incident involves manual Handling

If the incident involves a vehicle or motorised equipment

PART 2 - RECOMMENDATIONS

Table of Contents

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Unique ID

Incident and near Miss Number investigating

Who is involved in Completing this Investigation?

Incident / Injury: How do you think the incident / injury happened and what were they doing at the time?

How long had they been working prior to the incident / injury?

How long had they been working on this task?

Is this task part of their normal duties?

Have they been instructed / trained in this task?

What were they doing in the time prior to the incident / injury?

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

What do they think could have been done to prevent this incident from occurring?

Any other comments or observations?

What sort of incident / injury occurred?

Type of Injury

Was Safe work method Statement followed

Yes

Non Available

Location Of Incident

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Equipment in Good working order

Date of last service of equipment

Appropriate safety equipment (PPE) Used

Lighting Adequate

House keeping Issues Identified

Type of Surface

Type of shoes worn

Was their work load excessive

Was their work road boring or repetitive

Height of fall/ slip / trip

Were they running / walking / turning a corner / jumping / other?

If stairs – going up / going down?

Did you fall on your front / back / side?

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

Was a safety Data sheet Available

Disposal / handling / storage of chemical product adequate?

Were work items within easy reach?

Ergonomic equipment available?

Was the equipment being used correctly?

Repetitive and/or forceful movements used?

Action involved:

Weight of Object

Distance carried / position of object moved from / to?

Height of load?

Traffic Conditions

Weather conditions

Any Intersections, turns, driveways or straigh roads involved?

Speed Prior to Accident?

where were you traveling to?

Any other factors involved

Investigators Final Comments

RECOMMENDATIONS

Provide Actions required - By Whom - By When - A hierarchy of control should be used to assist with the prevention of future similar injuries. The ‘hierarchy of control’ depicts the most to the least effective method. ELIMINATION – do you have to do the task? SUBSTITUTION – is there another way you can do the task? ENGINEERING – can you engineer a way to make the job safer? ADMINISTRATION – can you improve work practices? E.g. limit time of exposure. PPE - Personal protective equipment

Date feedback provided to person reporting the injury/incident

Investigators Name

First Last

Investigators Title

Investigators Contact details

Investigators Signature

Section#

Para.#

Description of Change

Prepared By

Approved By

Issue#: 1 Issue Date: 13/7/2022

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