Please send to:

The Occupational Health and Safety Unit
Level 2, T.C. Lamble Building
The University of New England
Armidale NSW 2351
THE UNIVERSITY OF NEW ENGLAND
INCIDENT REPORT - STAFF
TO BE COMPLETED WITHIN
24 HOURS OF INCIDENT

ENSURE A COPY OF THIS REPORT IS KEPT FOR YOUR RECORDS
BEFORE SENDING TO THE OCCUPATIONAL HEALTH AND SAFETY UNIT

 

SECTIONS 1 - 5 to be completed by the Injured Worker

SECTIONS 6 - 7 to be completed by the Injured Workers immediate Supervisor

SECTION 1: Details of Injured/Ill Staff Member:
(a)

Surname:

...............................................................................................................................................................................................
(b)

Given Names:

...............................................................................................................................................................................................
(c)

Classification:

...............................................................................................................................................................................................
(d)

Cost Centre:

............................................................................

Phone No:

............................................................................
(e)

State Staff member's normal working hours:

.

..........................am/pm to........................am/pm
(e)

Did the injured/ill staff member continue work after the incident? (please tick one)


YES (Go to Section 2)

NO
(f)

Date and time work ceased:

Date: __ / __ / __

Time: ....................................................am/pm
(g)

Has the injured/ill staff worker returned to work since the injury?
SECTION 2: Injury/Illness Details
(a)

Type of injury (please tick where applicable)

Fracture/Dislocation

Skin Disorder

Damage to artificial aids

Burn/Scald

Contusion/Crush

Bite/Sting

Cut/Abrasion (First-aid only)

Poison

Strain/Sprain

Open Wound (Medical Treatment)

Amputation

Other..........................................
(b)

Bodily location of injury/illness:

.

...................................................................................................................................................................................................................................

...................................................................................................................................................................................................................................
SECTION 3: First-aid/Medical Treatment

If any First-aid and/or Medical treatment was required please state name and phone number of First-Aid /Medical attendant:
1.

Name:

.......................................................................................

Phone No:

.......................................................................................
2.

Name:

.......................................................................................

Phone No:

.......................................................................................
3.

Name:

.......................................................................................

Phone No:

.......................................................................................
SECTION 4: Details of Incident
(a)

Date of Incident:

__ / __ / __

Time of Incident:

.................................................................am/pm
(b)

Date incident reported:

__ / __ / __
(c)

Location of incident:

.........................................................................................................................................................................
(d)

Mechanism of the Injury/illness/dangerous occurrence. (please tick where applicable)


Slip, trip or fall

Body stress (exertion to muscles, tendons, ligaments & bone)

Mental Stress

Chemical or other substance exposure

Noise or Vibration

Hitting objects with part of the body

Struck by a moving object

Biological Exposure (germs, viruses & bacteria)
(e)

Brief description of incident:

.....................................................................................................................................................................

...................................................................................................................................................................................................................................

...................................................................................................................................................................................................................................
(f)

If any witnesses plase state name and phone number


1.

Name:

.............................................................................

Phone No:

.............................................................................
2.

Name:

.............................................................................

Phone No:

.............................................................................
3.

Name:

.............................................................................

Phone No:

.............................................................................

Any further comments:

.................................................................................................................................................................................................

.....................................................................................................................................................................................................................................................

.....................................................................................................................................................................................................................................................
SECTION 5: Declaration

To be completed by the injured/ill person:


I ..................................................................................................................... hereby declare that the information provided in the foregoing statement is true and correct.

Signature:

.................................................................................................................................

Date:

__ / __ / __

Name:

.................................................................................................................................
(Please Print)



Supervisor to complete

SECTION 6: Action
(g)

Action taken to prevent the incident from occurring in the future:

.....................................................................................................................

...................................................................................................................................................................................................................................

...................................................................................................................................................................................................................................
SECTION 7: Authorisation

To be completed by the Supervisor of the injured/ill person.


I ..................................................................................................................... declare that I have read this report in its entirety and have taken the relevant steps as described in Section 6. To my knowledge all information provided on this form by myself and the staff member is true and correct.

Signature:

.................................................................................................................................

Date:

__ / __ / __

Name:

.................................................................................................................................
(Please Print)