6.4.25 Incident / Injury Report Form

TO PRINT THIS FORM FROM THE POLICY LIBRARY, USE THE MS WORD LINK AT THE BOTTOM OF THE PAGE

Incident / Injury Report Form

Stop! Before completing this form the incident must be reported to a University supervisor to ensure area safety. If maintenance/repair is required please call 8888.

What should be reported?

§ Incident/accident

§ Injury, work caused illness and significant first aid treatment

§ Near miss (an incident which could have caused serious injury or extensive property damage but did not)

§ Dangerous event (eg failure of specified high risk plant, implosion, explosion or uncontrolled fire, collapse of a structure, escape of hazardous material or dangerous goods, object falling from height)

§ Property damage or hazardous activity observed.

If there has been a security breach or vehicle damage, use the following forms instead:

Security Incident Report Form in case of theft/suspicious person/event (Security Telephone: 7777)

Motor Vehicle Damage Report Form available from the Transport (Logistics) Office, Telephone: 387 57325.

What do you do with this form?

§ Save the Word document version of this form to your desktop, complete electronically and e-mail to relevant email address below

§ Print the form, complete manually and send to relevant element H&S area below

Where do you work or study?	Address to send form
Student, or a staff member belonging to an Academic Group	Email: safety@griffith.edu.au Mail: H&S Operational Unit, G09 1.65
Staff member in INS	Email: inssafe@griffith.edu.au Mail: H&S Coordinator, N53 1.24
Staff member in Campus Life	Email: clfsafe@griffith.edu.au Mail: H&S Coordinator, N11, 1.09
Staff member from non-academic areas, excluding INS & Campus Life	Email: stratsafe@griffith.edu.au Mail: Strategic H&S, N54, 1.26

§ If incident only: sections A and D are compulsory.

§ If an injury has occurred: the entire form must be completed

For assistance in completing this form contact your Local Health & Safety Contact or Element Workplace Health and Safety Officer (WHSO) listed at

http://www.griffith.edu.au/hrm/health_and_safety/content_contacts.html

or contact the Health & Safety Operational Unit on 555 28366.

Griffith University collects, stores and uses personal information only for the purposes of administering workplace health & safety risk management. The information collected is confidential and will not be disclosed to third parties without your consent, except to meet government, legal or other regulatory authority requirements. For further information consult the University's Privacy Plan at www.griffith.edu.au/ua/aa/vc/pp

Office Use Only
Incident #:		Date Entered:
Injury #:		Entered by:
Incident Date:		Injured/Involved person:

Section A: Details of incident

Injury	Work related illness	Non work-related illness	Property damage
Dangerous event	Electrical incident	Environmental incident	Near miss

Name of person completing report:
Name:			Contact telephone:
Date incident occurred:			Time incident occurred:

Incident occurred while:
At work	Travelling to/from work	On meal break
Student work placement : ______________		Other: _______________________________
Date reported:		Reported to:

Site of Incident:
Nathan	Gold Coast	South Bank	Off campus
Logan	Mt Gravatt	Student work placement

Exact location details: (external area / building & room etc)

What happened? (What were you doing at the time of the incident? Briefly describe how it happened.)

Were any government agencies called to the incident? eg Police, Fire Services etc

No Yes (if yes provide details)

List any witnesses: (names, telephone contact details, ID No if applicable)

Section B: Details of injured person and injury

Family Name:		Given name/s:
Student/Staff ID:		M F
Date of birth:		Telephone:
Position title:		School/Element:

Employment status:
Academic staff	General staff	College resident	Griffith student
Contractor*	Child	Visitor/member of public	Volunteer
Other:
* Name of contracting company:

Employment basis:
Full-time	Part-time	Casual

Name of injured person's supervisor:

Details of treatment required:
None	Self	First aid **
Campus Medical Centre	Seen by other Medical Doctor	Hospital
**Describe first aid treatment given:

Nature of injury:
Allergy or sensitivity	Exposure effects heat/cold	Occupational overuse injury
Amputation	Fainting	Poisoning/toxic effects
Asphyxiation	Foreign body	Post - traumatic shock
Bruising	Fracture/dislocation	Psychological disorder/stress effects
Burn / scalds	Hearing loss	Puncture
Communicable disease	Hernia	Respiratory
Concussion or other neuro injury	Internal injuries	Skin condition eg dermatitis/ eczema
Contusion/crush	Laceration/deep cut	Superficial wound or abrasion
Damage to artificial aids	Multiple injuries	Sprain/strain
Electric shock or effects	Nausea/vomiting	Vision impairment

Part of body affected:

Left

Right

Head

Neck

Forearm

Chest

Buttock

Shin/calf

Face

Shoulder

Wrist

Back

Thigh

Ankle

Ear

Upper arm

Hand

Stomach/trunk

Knee

Foot/toe

Eye

Elbow

Fingers/thumb

Groin/hip

Internal

Further description of injury/illness (if required):

Agency of injury (what?)
Animal/Insect	Mobile plant/equipment	Radiation
Biological agent (eg pathogens)	Needle/sharp	Repetitive work
Chemical	Noise	Situation – violence, assault
Electrical	Non-power tool	Surface (slippery/rough)
Explosion/implosion	Objects	Thermal (heat/cold)
Lifting/ Carrying	Power tools	Vehicle/transport
Machinery/fixed plant	Psychological/social	Workstation design
Other (please specify):

Action/ mechanism which caused injury (how?)
Exposure to biological material	Hit by/trapped in moving object	Needlestick: non-contaminated
Exposure to chemicals	Hitting object	Needlestick: potentially contaminated
Exposure to electricity	Insect/animal bite	Noise
Exposure to heat/cold	Mental stress factors	Pressure
Exposure to radiation	Muscle stress- loads	Slip/trip/fall at same level (requires further investigation)
Exposure to vibration	Muscle stress – repetitive	Vehicle accident
Fall from height
Other (please specify):

Section C: Incident Investigation

This section is to be completed by the local manager or safety specialist for any incident involving personal injury, and for a serious incident or near misses where required.

Some incidents may require a more detailed investigation (eg slips, trips and falls). See Incident Investigation Guidelines http://www.griffith.edu.au/hrm/health_and_safety/doc/incident_investigation_guidelines.doc

Identify any factors contributing to the incident.
Number in order from most direct cause (1) to other underlying causes (2, 3, etc)
Design issues		Inadequate supervision
Environment (e.g. floor/ground surface)		Inadequate/lack of training
Failure to follow work procedures		Lack of appropriate Personal Protective Equipment
Improper use/storage of materials		Lack of experience
Inadequate equipment functioning		Personal factors-stress, fatigue
Inadequate equipment maintenance		Poor housekeeping
Inadequate safety procedures		Poor/lack of suitable equipment
Inadequate space		Unforeseeable event
Other environmental conditions (e.g. weather, lighting, ventilation, temperature)

Preventative/Corrective Actions:
Describe the follow up actions planned or taken to prevent a similar incident.
Action/s (Short Term and Longer Term)	Who / Section	Completion date

Please attach extra pages, if required, for investigation and actions.

Section D: Acknowledgements

(This signature confirms that notification of the above incident has been received)

In order to ensure timely response to this incident, please ensure your Local Health & Safety Contact or element Health & Safety specialist is notified by phone or email as soon as possible.

Local Supervisor/Manager:
Name:
Comments:
Date:	Telephone:	Signature:

Safety Specialist/Other relevant personnel:
Name:
Comments:
Date:	Telephone:	Signature:

Element Director/Head of School:
Name:
Comments:
Date:	Telephone:	Signature:

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