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Hope Church Incident Record Form

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Please enter the details for the new Incident Record

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2
Incident Description
Provide a simple title or summary of the incident e.g. nearly fell off a step ladder, strained my back lifting heavy box
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3
Nature & seriousness of the incident?
Near Miss Incident/Hazard - An incident occurred, no one got hurt but there was the potential for an injury
  • A Incident resulting in injury
  • B Near miss incident
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4
How serious was the injury?

First Aid - injury was treated by a first aider onsite

Medical Treatment - injury required treatment by a medical practitioner

Immediate Medical Treatment - injury required by emergency service treatment e.g. Ambulance
  • A First Aid
  • B Medical Treatment
  • C Immediate Medical Treatment
  • D Not Applicable
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5
Incident Details
Provide as much details as you can and describe what happened?

Include the name of any particular chemical, product, process you were following or equipment involved.

E.g. fell off step ladder used to access shelving in chair storage room
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6
Date of Incident
Please answer in this format: DD/MM/YYYY
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Please answer in this format: DD/MM/YYYY
7
Time incident occurred
Please answer in 24hr format (e.g. 1400)
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Please answer in 24hr format (e.g. 1400)
8
Address where the incident occurred
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9
Specific worksite area incident occurred
e.g. first floor corridor, in the ground floor toilet, in Moriah 2
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10
Were there any witnesses?
  • A Yes
  • B No
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11
Name of witness one
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12
Contact details of witness one
Please provide email address
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13
Contact details of witness one
Please provide mobile number
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14
Add another witness?
  • A Yes
  • B No
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15
Name of witness two
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16
Contact details of witness two
Please provide email address
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17
Contact details of witness two
Please provide mobile number
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18
Who reported the incident?
Please provide your name
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19
Please attach any photos of the venue, and hazard or injury
Maximum file size: 10MB
Uploaded
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20
Are you a
  • A Staff
  • B Contractor
  • C Volunteer
  • D Ministry leader
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21
Please provide your contact details
Please provide email address
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22
Please provide your contact details
Please provide mobile number
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25
Who was injured or nearly injured?:
Please provide the name
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26
Gender
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27
Please provide the person's contact details
Please provide email address
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29
Please provide the person's contact details
Please provide mobile number (04XXXXXXXX)
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29
Please provide the person's date of birth
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Incident Sub Injury Details - Treatment - Rehabilitation
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31
How was the injury sustained:
How exactly was the injury or disease sustained? Include the name of any chemical, product, process or equipment involved

e.g. hit head on shelf when climbing the ladder, pain in neck after sitting at workstation for long duration
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32
Nature of Injury
  • A Fractures [excluding of vertebral column]
  • B Fracture of vertebral column with or without mention of spinal cord lesion
  • C Dislocations
  • D Sprains and strains of joints and adjacent muscles [ including acute trauma sprains and strains only]
  • E Intracranial injury, including concussion
  • F Internal injury of chest, abdomen and pelvis
  • G Traumatic amputation, including enucleation of eye [loss of eyeball]
  • H Open wound not involving traumatic amputation
  • I Superficial injury
  • J Contusion with intact skin surface and crushing injury, excluding those with fracture
  • K
    Foreign body on external eye, in ear or nose or in respiratory, digestive or reproductive systems [including choking]
  • L
    Burns
  • M Injuries to nerves and spinal cord without evidence of spinal bone injury
  • N Poisoning and toxic effects of substances
  • O
    Effects of weather, exposure, air pressure and other external causes [including bends, drowing, electrocution]
  • P Multiple injuries [only to be used where no principal injury can be identified]
  • Q Damage to artificial aids
  • R Other and unspecified injuries
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33
Location on the body of injury/disease:
  • A Eye
  • B Ear
  • C Face
  • D Head [other than eye, ear and face]
  • E Neck
  • F Back
  • G Trunk [other than back and excluding internal organs]
  • H Shoulders and arms
  • I Hands and fingers
  • J Hips and legs
  • K Feet and toes
  • L Internal organs [located in the trunk]
  • M Multiple locations [more than one of the above]
  • N General and unspecified locations
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34
Was first aid received?
  • A Yes
  • B No
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35
Details of the first aid provided
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36
Did the injured person see a doctor?
  • A Yes
  • B No
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37
Provide details of treatment received
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38
Was hospital treatment required?
  • A Yes
  • B No
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39
Detail hospital treatment provided
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40
Was Rehabilitation required?
  • A Yes
  • B No
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42
Detail rehabilitation treatment provided
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Incident Investigation
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54
Identify immediate causes
e.g. the ladder was broken: List immediate causes that appear to have directly contributed to the incident e.g. unsafe acts & conditions.

Consider: What? Why? How? Who? When? Was there compliance with procedures, training, supervision, use of PPE, operation of plant / equipment, environmental factors
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55
Identify root causes
List the root causes - underlying basic causes. These typically involve safety systems. e.g. domestic step ladders were in use at the workplace, there was no safe work procedure for safe use of ladders, there was no process to inspect condition of ladders on a regular basis, there was no staff training regarding safe use of ladders
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