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Create A New Hope Church 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
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5
Incident description / name
Describe the task/s you were doing when the incident happened e.g. placing stock on shelves, mowing the grass

Incident details to be given in the next question
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6
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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7
Date of Incident
Please answer in this format: DD/MM/YYYY
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8
Time incident occurred
Please answer in 24hr format (e.g. 1400)
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9
Address where the incident occurred
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10
Specific worksite area incident occurred
e.g. first floor corridor, in the ground floor toilet, in Moriah 2
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11
Were there any witnesses?
  • A Yes
  • B No
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Name of witness one
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13
Contact details of witness one
Please provide email address
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14
Contact details of witness one
Please provide mobile number
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15
Add another witness?
  • A Yes
  • B No
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16
Name of witness two
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Contact details of witness two
Please provide email address
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18
Contact details of witness two
Please provide mobile number
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19
Who reported the incident?
Please provide your name
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20
Please attach any photos of the venue, and hazard or injury
Maximum file size: 10MB
Uploaded
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21
Are you a
  • A Staff
  • B Contractor
  • C Volunteer
  • D Ministry leader
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22
Please provide your contact details
Please provide email address
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23
Please provide your contact details
Please provide mobile number
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24
Were other PCBUs involved?
PCBU is a persons conducting a business or undertaking
  • A Yes
  • B No
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25
Detail other PCBUs involved:
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26
Who was injured or nearly injured?:
Please provide the name
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27
Gender
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28
Please provide the person's contact details
Please provide email address
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30
Please provide the person's date of birth
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30
Please provide the person's contact details
Please provide mobile number (04XXXXXXXX)
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Incident Sub Injury Details - Treatment - Rehabilitation
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32
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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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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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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Mechanism of injury/disease:
  • A Falls from a height
  • B Falls on the same level [including trips and slips]
  • C Hitting objects with a part of the body
  • D
    Exposure to mechanical vibration
  • E Being hit by moving objects
  • F Exposure to sharp, sudden sound
  • G Long term exposure to sounds
  • H Exposure to variations in pressure [other than sound]
  • I Repetitive movement with low muscle loading
  • J Other muscular stress
  • K Contact with electricity
  • L Contact or exposure to heat and cold
  • M Exposure to radiation
  • N Single contact with chemical or substance [excludes insect and spider bites and stings]
  • O Long term contact with chemical or substance
  • P Other contact with chemical or substance [includes insect and spider bites and stings]
  • Q Contact with, or exposure to, biological factors
  • R Exposure to mental stress factors
  • S Slide or cave-in
  • T Vehicle accident
  • U Other and multiple mechanisms of injury
  • V Unspecified mechanisms of injury
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Was first aid received?
  • A Yes
  • B No
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Details of the first aid provided
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Did the injured person see a doctor?
  • A Yes
  • B No
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Provide details of treatment received
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Was hospital treatment required?
  • A Yes
  • B No
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Detail hospital treatment provided
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42
Was Rehabilitation required?
  • A Yes
  • B No
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Start date of rehabilitation program
Please answer in this format: DD/MM/YYYY
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44
Detail rehabilitation treatment provided
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45
Did the worker require time off work?
  • A Yes
  • B No
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Date they stopped work
Please answer in this format: DD/MM/YYYY
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Date they returned to work
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48
Enter the time lost
Consider the individuals normal hours of work to accurately calculate the real time lost (number of day)
Please answer in this format: HH:MM
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Incident Investigation
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50
Is this incident a Notifiable Event?
An incident is notifiable if it arises out of the conduct of a business or undertaking and results in the death, serious injury or serious illness of a person, or involves a dangerous incident

Refer to Safe Work Australia's Incident Notification Information Sheet

https://www.safeworkaustralia.gov.au/doc/incident-notification-fact-sheet


  • A Yes
  • B No
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Is Immediate notification required?
Have you notified the regulator of the event?

A notifiable incident must be reported to the regulator as soon as possible after it has occurred
  • A Yes
  • B No
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52
Is Site Preservation required:
A site where a notifiable event has occurred must be preserved until an inspector arrives or directs otherwise. Requirements to preserve a site only apply to the area where the notifiable event occurred-not the whole workplace.
  • A Yes
  • B No
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53
Date of Immediate Notification
Immediate Notification usually occurs via email or phone call to the Regulator
Please answer in this format: DD/MM/YYYY
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54
Date of Written Notification
If the regulator asks - written notification must be made within 48 hours of the request. Falling to report a "notifiable event" is an offence and penalties apply.
Please answer in this format: DD/MM/YYYY
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55
Were any other PCBU/s involved?
  • A Yes
  • B No
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Details of other PCBU/s
Please provide an email or phone number
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Who notified the regulator?
  • A Our Organisation
  • B Other PCBU
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58
Identify the other PCBU
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Date they notified the regulator
Please answer in this format: DD/MM/YYYY
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Has an investigation been completed?
  • A Yes
  • B No
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61
Date investigation was undertaken
Please answer in this format: DD/MM/YYYY
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Date investigation was complete
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63
Person responsible for investigation
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64
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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65
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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Incident Risk Treatment
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67
Has a new hazard or risk been identified?
If the incident identified a new hazard ensure you enter this new hazard on the risk register
  • A Yes
  • B No
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Name of Risk Register item:
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Date new Risk Register item added:
Please answer in this format: DD/MM/YYYY
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70
Is risk treatment required?
  • A Yes
  • B No
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71
Objective of the risk treatment
Please select one option from below:
  • A Eliminate the hazard and the risk
  • B Minimise the hazard and the risk
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Risk Treatment Selected
  • A Elimination
  • B Substitution
  • C Engineering Controls
  • D Administrative Controls
  • E Personal Protective Equipment
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Elimination Risk Treatment
e.g. our process requires the task to be completed on solid ground, not at height
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Elimination Priority Order:
Please select an option from below (1 - highest priority, 5- lowest priority)
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Elimination Due Date:
Please answer in this format: DD/MM/YYYY
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Elimination Date Completed:
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77
Substitution Risk Treatment
e.g. the chemical used was a less hazardous alternative to the previous chemical used for this task
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Substitution Priority Order:
Please select an option from below (1 - highest priority, 5- lowest priority)
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Substitution Due Date:
Please answer in this format: DD/MM/YYYY
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Substitution Date Completed:
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81
Engineering Controls Risk Treatment
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Please select an option from below (1 - highest priority, 5- lowest priority)
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Engineering Controls Due Date:
Please answer in this format: DD/MM/YYYY
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84
Engineering Controls Date Completed:
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85
Administrative Controls Risk Treatment
e.g. a safe work procedure has been developed for this task
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86
Administrative Controls Priority Order:
Please select an option from below (1 - highest priority, 5- lowest priority)
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87
Administrative Controls Due Date:
Please answer in this format: DD/MM/YYYY
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88
Administrative Controls Date Completed:
Please answer in this format: DD/MM/YYYY
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89
PPE Risk Treatment
e.g. a safety boots and high visibility vests are provided and must be worn by staff who access the warehouse
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90
PPE Priority Order:
Please select an option from below (1 - highest priority, 5- lowest priority)
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91
PPE Due Date:
Please answer in this format: DD/MM/YYYY
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92
PPE Date Completed:
Please answer in this format: DD/MM/YYYY
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