HAZARD, NEAR MISS, OTHER INCIDENT AND INJURYILLNESS REPORT.pdf - ATTACHMENT 91 HAZARD NEAR MISS OTHER INCIDENT AND INJURY\/ILLNESS REPORT(REGISTER OF

HAZARD, NEAR MISS, OTHER INCIDENT AND INJURYILLNESS REPORT.pdf

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© 2011 Kindergarten Parents Victoria Telephone 03 9489 3500 or 1300 730 119 (rural) ATTACHMENT 91 HAZARD, NEAR MISS, OTHER INCIDENT AND INJURY/ILLNESS REPORT (REGISTER OF INJURIES) AND INVESTIGATION FORM Complete relevant part(s) of the form and forward to employer as soon as possible. PART 1: NOTIFICATION OF HAZARD OR INCIDENT Name of person reporting the hazard, near miss or incident (optional): ……………………………………………... Department: …………………………………………………………… Section: ……………………………………….. Hazard, near miss or incident locat ion: …………………………………………………………………………………. . Date of incident: ………………………………………………………. Time of incident: ………. AM PM Detailed description of hazard, near miss or incident including all immediate and underlying factors contributing to the incident. Consider: (i) plant, machines, tools, equipment (ii) materials (iii) environment, physical layout (iv) people, knowledge, training, behaviour, culture, supervision (v) methods, procedures ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… PART 2: DETAILS OF ANY PERSON INJURED Surname of injured/ill person: ………………………………………... First name(s): ………………………………… Private address: ……………………………………………………………………………………………………………. Work location of injured person: ………………………………………………………………………………………….
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