Incident Report Form
This Incident Report Form should be completed in relation to all Incidents. The objective of the form is to identify facts and modify management systems to prevent a recurrence. It is critical not to attribute blame.
1. FACT FINDING (TO BE COMPLETED AT THE SCENE OF THE INCIDENT)
Persons involved in Incident (repeat table if multiple persons involved)
Persons with disability affected by the Incident (repeat table if multiple persons with disability involved)
Workers involved in Incident (repeat table if multiple Workers involved)
Witnesses (repeat table if multiple witnesses)
Incident Details (to the extent known)
2. INCIDENT INVESTIGATION (TO BE COMPLETED AFTER THE FACTS HAVE BEEN GATHERE)
Findings in relation to how the incident occurred
(list steps that led to the incident or refer to external report)
Findings in relation to how the Incident impacted on, or cause harmed to, any person involved (including persons with disability)?
(list effects of the incident or refer to external report)
List possible contributing factors (refer to following table of potential contributing factors)
(This list provides the more common contributing factors; it is not an exhaustive list.)
Liquid or chemical
Low light levels
Written job procedures
Storage or stacking
Hours of work
List all essential contributing factors.
Essential Contributing Factors are those that satisfy the question “Would the incident have still occurred if this factor had not been present?”
Preventative and corrective actions
Report in relation to preventative and corrective actions
Refer to the Hierarchy of Control below and the following list of preventative / corrective actions.
|Change to induction|
|Change to work|
|Change to ongoing|
|Change to work|
|Equipment / machinery|
3. PREVENTATIVE AND CORRECTIVE ACTION TO BE TAKEN
Hierarchy of Control
Can another work method or piece of equipment be used, hence eliminating this hazard?
Can the hazard source be replaced with less hazardous equipment, materials or processes
3. ENGINEERING CONTROLS
eg. Ventilation of confined spaces or other areas
4. ADMINISTRATIVE CONTROLS
eg. Worker rotation, Worker dismissal, hiring procedures, safe work procedures, inspections/audits.
5. PERSONAL PROTECTIVE EQUIPMENT
eg. Respiratory protection, safety harnesses, safety glasses/goggles, gloves.
4. INCIDENT RESOLUTION WITH RESPECT TO PERSON(S) INVOLVED
The Incident Manager will consult Clients (including persons with disability), family and advocates at regular intervals in connection with the management, resolution and any decision in relation to the Incident. In addition, such consultation(s) will involve obtaining the Client’s views in relation to the Incident.
Consultation (repeat table if multiple persons consulted with)
6. CONTINUOUS IMPROVEMENT
The Incident Manager should obtain the feedback of appropriate Workers in connection with the Incident management procedure to ensure that it remains relevant and to ensure that it remains relevant and continues to reflect the actual manner in which Incident Management activities are undertaken.
Worker Feedback (repeat table if multiple persons provided feedback)