Template 1 Incident Report Form Note All sections of this form are to be

Template 1 incident report form note all sections of

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Template 1 – Incident Report Form Note: All sections of this form are to be completed. All incidents shall be advised within 12 hours of the incident to ensure appropriate action is initiated. Personal details Family name: First name: Contact Phone No: (w) (h –if injured) Occupation: Gender: M F Staff employment status: Full-time Part-time Casual Contractor Visitor Division/Department: Incident details Date of incident: Time of incident: AM / PM Location where incident occurred: BSBWHS401 Implement and monitor WHS policies, procedures and programs to meet legislative requirements V2-2020 Page 11 RTO Provider: 91153 - CRICOS Code: 02672K greenwichcollege. edu.au
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Briefly describe what happened: This incident resulted in: Injury No injury Near miss Property damage Hazard identified The incident was reported to (Supervisor): Name of Supervisor:______________________________________ Date: _________ Injury/damage details If an injury was sustained, what part of the body was affected; or if damage to property occurred, what was damaged? BSBWHS401 Implement and monitor WHS policies, procedures and programs to meet legislative requirements V2-2020 Page 12 RTO Provider: 91153 - CRICOS Code: 02672K greenwichcollege. edu.au
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Medical treatment If MEDICAL EXPENSES or LOST TIME is incurred, a Workers Compensation Claim form must be completed and forwarded to WHSW & IM Services as soon as possible. Do you intend to seek medical treatment? Yes No Do you intend to lodge a claim for workers compensation? Yes No Has any time been lost from work? (More than 1 complete shift) Yes No If so, have you returned to work? Yes No Have medical expenses been incurred/will medical expenses be incurred? Yes No Uncertain at this time Were there witnesses? If so, provide name of witness(es): Witness(es) contact phone number: BSBWHS401 Implement and monitor WHS policies, procedures and programs to meet legislative requirements V2-2020 Page 13 RTO Provider: 91153 - CRICOS Code: 02672K greenwichcollege. edu.au
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Employee signature: Date: If a medical certificate has been provided, please send to: Fax xxxx xxxx or email: [email protected] Describe in detail what occurred It is the responsibility of the supervisor/line manager to complete this section in consultation with the injured staff member. Please describe the events and contributing factors that led to the incident (2): How could this be prevented from happening again? The supervisor/line manager is to complete this section in consultation with the injured staff member and the health and safety representative (if applicable). Suggestions to avoid recurrence of this incident/accident (2): BSBWHS401 Implement and monitor WHS policies, procedures and programs to meet legislative requirements V2-2020 Page 14 RTO Provider: 91153 - CRICOS Code: 02672K greenwichcollege. edu.au
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Name of health and safety representative, if consulted: Action plan Note: From the previous section, list the actions required to prevent this happening again.
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