IMPORTANT! This document is for incidents only: Damage to either property or stock Reporting in ADS Category 1 within 6 hours, Category 2 within 12 hours, Category 3 within 24 hours All incidents to be investigated within 3 working days

INCIDENT REPORT & INVESTIGATION

“Matching the right people to you”

This form is fillable.

DETAILS OF PERSON COMPLETING THIS FORM	REPORT NO.(OFFICE USE ONLY):

Surname:	First Name(s):
Contact Phone No:	Date:	20/03/2021 1:53:39 PM
Email:

2	DETAILS OF INJURED / ILL PERSON

Surname:	First Name(s):
Address:
State	Email:
DOB:	Contact Phone No:
Department:	Date:	Click or tap to enter a date.

3	DESCRIPTION OF INCEIDENT

Date:	Click or tap to enter a date.	Time of hazard:	: ☐ AM ☐ PM
Where did it happen?
What task was being undertaken at the time
Were there any tools or equipment involved?	☐ Yes ☐ No
If yes, provide details:
Have the tools in question been tested?	☐ Yes ☐ No
Who is responsible for the damages?

Describe what happened:

4.Witnesses:

Were there any witnesses?	☐ Yes ☐ No
Name:	Contact:
Name:	Contact:
Name:	Contact:

Who was the incident reported to?
Position:
What was the perceived cause of the accident?

5.DAMAGE DETAILS

What was damaged/lost?	☐Property ☐ Product ☐ Vehicle
Classification: Category 1 - Damage due to an incident or disaster that entails compensation or insurance payment of any amount equivalent to or more than AUD$50,000 (Input into ADS)" Category 2 - Damage due to an incident or disaster that involves economic loss value between $10,000 - $50,000 (Input into ADS) Category 3 - Damage due to an incident or disaster value below $10,000 (Input reportable incidents into ADS) Estimated Cost of Damage/ Loss: (AUD)$ Please send all incident damage reports to your line manager, Quality Manager & Safety manager. The line manager MUST complete the incident investigation with the person completing this form and submit to the Quality & Safety Manager within 5 days. INJURY/ ILLNESS DETAILS

☐ if others, provide full details

6.ROOT CAUSE ANALYSIS

Problem Definition (Work backwards - What happened? Eg: the driver fell off a tail gate and hurt his leg)

Why did this happen? (eg: Because the load became unbalanced and was starting to fall)

Why did this happen? (eg: Because the driver accidently stepped on the kick plate safety mechanism)

Root Cause (eg: Human error due to lack of training)

7.INDICATIVE EVIDENCE

You must provide evidence to support your statement on the Root Cause of the accident/ illness. For example, if the Root Cause was identified as ' Human error due to lack of training' you need to provide evidence that there was a lack of training (incomplete induction and training records, no SOP signed by the operator, etc)

Indicative Evidence 1

Indicative Evidence 2

Indicative Evidence 3

Are there any photographic images of the hazard?	☐ Yes	☐ No
Was the accident caught on CCTV?	☐ Yes	☐ No

When lodging this Report please ensure you include any and all videos and/or photos

8.WITNESSES

If there were any witnesses to this accident, please ensure to document their statements as soon as possible. Be sure to include the witnesses full name, contact number, time and date of interview. All witness statements should be copied and lodged with this report.

Questions for a witness:

The witness MUST sign and time/date his/her own statement & Interviewer must also sign statements

Exactly what did you see?
Where were you when this happened?
What was the injured person doing when the accident happened?
What caused the accident?
What makes you think/ say that?

Was this hazard preventable?	☐ Yes	☐ No

If Yes, How?

If No, Why Not?

☐ By ticking this box, I confirm that all the information I have provide is true and accurate to the best of my knowledge . I also acknowledged all budget workforce terms and conditions, privacy policies and local laws.

Witness Full name (Capital letters) Signature

DATE:

Click or tap to enter a date.

Name of Person completing this report	Signature

9.CORRECTIVE/ PREVENTATIVE ACTION	(SUPERVISIOR OR SITE INCHARGE TO COMPLTETE THIS SECTION )

What countermeasures are we going to take to reduce the risk of this hazard occurring again?

Countermeasure	By When?	By Who?

1
2
3
4
5
6

Who else has been notified?

☐ Police	☐ Fire Brigade ☐ Landlord

☐ Local Council ☐ Customer	☐ Other:

Name of Operational Owner	Signature