Confidential Incident / Injury / Near Miss Report Form

PART 1 - INITIAL NOTIFICATION

(TO BE COMPLETED AND SENT TO UWA SAFETY, HEALTH AND WELLBEING WITHIN 24 HOURS)
TO COMPLETE ON SCREEN - TAB BETWEEN FIELDS MAKING ENTRIES BY TYPING INTO THE GREY HIGHLIGHTED BOXES WHICH EXPAND AS REQUIRED

INJURED PERSONS DETAILS

REPORTING PERSON DETAILS (if different to injured person)

Title:

Last Name:

Gender:

Other names:

Student:

Contractor:

Date of Birth:
Visitor:

Occupation:

Are you: Staff:

Staff/Student No:
Student:

Contractor:

Visitor:

Occupation:

Work phone:

Home:

Work phone:

Home:

Email:

Mobile:

Email:

Mobile:

Gender:

Title:

Other names:
Staff/Student
No:

Date of Birth:
Are you: Staff:

Last Name:

Faculty / Contracting Company:

Faculty / Contracting Company:

School / Centre:

School / Centre:

Home address:

Home address:

State:

Postcode:

State:

Postcode:

INCIDENT DETAILS - for electrical incidents, immediately also notify FM Technical Officer (Electrical) on (08) 6488 2031
or Building Services Electrical Supervisor on (08) 6488 2016

Incident

Injury

Exact Location:

Near miss

Illness/disease

Date of occurrence:

Time: (am / pm)

How did the incident/injury happen (please provide a step by step account):

Witness1:

Witnes
s2:
Phone:

Phone:

DETAILS OF INJURY, ILLNESS OR DISEASE

Type of injury or disease (e.g. bruise, cut, sprain):

Part(s) and side of the body affected:

Please specify when were the symptoms first noticed:

Noticed on Date:

None
Other:
Treatment Date:

Medical treatment: Hospital

Person giving treatment:

Doctor

Nurse

First Aid

Time: (am /
pm)
Time: (am /
pm)

NOTIFIED SUPERVISOR / MANAGER

Name:

How notified:

Date Notified:
In
person

By
phone

By
email

Time: (am / pm)

Othe
r

NOTIFIED HEALTH AND SAFETY REPRESENTATIVE

Name:

How notified:

Date Notified:
In
person

By
phone

By
email

Time: (am / pm)

Othe
r

Email form to Safety, Health and Wellbeing

Confidential Incident / Injury / Near Miss Report Initial Notification

Publishe May 2015

d:
Authorised by UWA Safety, Health and Wellbeing
Review:
May 2020
This document is uncontrolled when printed - the current version is on the Safety, Health and Wellbeing website

Version 2.0
Page 1 of 3

Confidential Incident / Injury / Near Miss Report Form

PART 2 - SUPERVISOR / MANAGER INVESTIGATION

(TO BE COMPLETED AND SENT TO UWA SAFETY, HEALTH AND WELLBEING WITHIN FIVE WORKING DAYS)
TO COMPLETE ON SCREEN - TAB BETWEEN FIELDS MAKING ENTRIES BY TYPING INTO THE GREY HIGHLIGHTED BOXES WHICH EXPAND AS REQUIRED

WORKERS COMPENSATION / LOST TIME

Person who was injured or involved in incident:

Date of injury / incident:

If a UWA employee, does the injured person intend to lodge a workers compensation claim? Yes

No

Unknown

(IF YES, AN ADDITIONAL FORM MUST BE COMPLETED)

Will time be lost as a result of the injury?

Yes

How many hours/days?

WAS THE ACCIDENT A SLIP, TRIP OR FALL?

Was there adequate lighting?

Was housekeeping a contributing factor?

Time of day:
Specific Location:

Indoors

No

If YES complete below

If NO go to next section

Outdoors
(covered)

Dawn/Dusk
Outdoors
(uncovered
)

Daylight

Night

Steps /
Stairs

Walkway

*** PLEASE ATTACH A DIAGRAM OF WHERE THE SLIP / TRIP / FALL OCCURRED, SHOWING EXACT LOCATION, IF APPROPRIATE ***

Type of surface:

Carpet

Cement

Gravel
Road
Rocks
Other (explain):

Shoe type worn:

Boots
Closed
Other (explain):
Were they:
Jumping
Running
Other (explain):

If Slip / Trip or Fall occurred on stairs, were they?

Did they fall on their?
Where they carrying anything at the time?
No
DID THE INCIDENT INVOLVE A MANUAL TASK?
Were work items within easy reach?
Was ergonomic equipment available?
Was the equipment being used correctly?
Repetitive and/or forceful movements used?
Weight of the object being moved:
Did the action
involve?
Other (explain):

Bending

Catching

Pulling

Pushing

Damaged

Dry

Sand

Tile

Footpat
h
Torn

High heels

None

Open

Walking

Wet
Sandals

Turning around a corner

Descending
Back
Yes

Ascending
Front
Side
Details:
If YES complete below
If NO go to next section
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Load height:
Distance carried:
Lowerin
Carrying
Kneeling
Lifting
g
Reaching
Sitting
Stooping
Twisting

DID THE INCIDENT INVOLVE EQUIPMENT / PLANT?

Describe the equipment / plant involved?
Was the equipment in good condition?
Standard Operating procedure followed?
Was appropriate safety equipment (PPE) used?
DID THE INCIDENT INVOLVE CHEMICALS?
Was a Material Safety Data Sheet (MSDS) available?
Were storage, handling, disposal practices adequate?
Was Job Safety Analysis (inc. Risk Assessment) done?

Grass

If YES complete below

Yes
Yes
Yes
Yes
Yes
Yes

If NO go to next section

No
Last service date:
No
N/A
No
N/A
If YES complete below
If NO go to next section
No
N/A
No
N/A
No
Date completed:

*** PLEASE ATTACH THE MSDS, IF APPLICABLE ***

TICK BOXES TO INDICATE IF ANY OF THE FOLLOWING FACTORS CONTRIBUTED TO THE INCIDENT:
Environment workplace/task design
Inadequate supervision
Failure to follow work procedures
Inadequate training
Improper use/storage of materials
Personal Protective Equipment inappropriate/not used
Inadequate equipment function
Lack of experience in task/not competent
Inadequate equipment maintenance
Poor/lack of suitable equipment
Inadequate safety procedures
Untidy work area
Inadequate space
Personal factors
Environmental conditions
(e.g. stress, fatigue, pre-existing medical condition)
(e.g. weather, lighting, ventilation, temperature)
Confidential Incident / Injury / Near Miss Report - Supervisor / Manager Investigation

Publishe May 2015

d:
Authorised by UWA Safety, Health and Wellbeing
Review:
May 2020
This document is uncontrolled when printed - the current version is on the Safety, Health and Wellbeing website

Version 2.0
Page 2 of 3

Confidential Incident / Injury / Near Miss Report Form

PART 2 - SUPERVISOR / MANAGER INVESTIGATION

(TO BE COMPLETED AND SENT TO UWA SAFETY, HEALTH AND WELLBEING WITHIN FIVE WORKING DAYS)
TO COMPLETE ON SCREEN - TAB BETWEEN FIELDS MAKING ENTRIES BY TYPING INTO THE GREY HIGHLIGHTED BOXES WHICH EXPAND AS REQUIRED

Other (explain):

INCIDENT / INJURY:
Please provide detail of what injured person was doing prior to the incident and what tools or equipment were being used:

INFORMATION RELATING TO COMPETENTLY CARRYING OUT THE TASK OR ACTIVITY:

Were they instructed or trained to ensure competence?
Yes
No
How long had they been working on
this task?
Were they following a procedure or directly supervised? Yes
No
Was the task part of the staff members normal duties?
Yes
No
If No to any of the above questions, please explain why they were carrying out the task:

INVESTIGATORS COMMENTS AND OBSERVATIONS:

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 methods, as shown in the table below. Please complete all sections.
RECOMMENDATIONS TO PREVENT REOCCURENCE OF THIS HAZARD:
RISK CONTROL
OPTIONS

REQUIRED ACTION

BY WHOM

BY WHEN

Elimination (e.g.
remove)

Substitution (e.g.
alternate)

Engineering (e.g.
controls/guards)

Administration (e.g.
standard operating
procedures,
training)

Personal Protective
Equipment (e.g.
safety glasses,
helmets, gloves)

Date:

Mailbag:

Manager/Supervisor name:

Signature:

Phone:

Head of School/School Manager name: Signature:

Phone:

Date:

Mailbag:

Safety & Health Representative name:

Phone:

Date:

Mailbag:

Signature:

SAFETY AND HEALTH USE ONLY - RECOMMENDATIONS

Is further investigation required?
Comments:

Yes

Safety and Health Advisor name:

Signature:

No

Confidential Incident / Injury / Near Miss Report - Supervisor / Manager Investigation

Date:

Publishe May 2015

d:
Authorised by UWA Safety, Health and Wellbeing
Review:
May 2020
This document is uncontrolled when printed - the current version is on the Safety, Health and Wellbeing website

Version 2.0
Page 3 of 3