Hitting object with body Being hit by Being hit by a Being trapped or moving/falling person accidentally caught by moving object equipment Being bitten by an Being exposed to Exposure to noise Muscular stress while animal vibrating machinery lifting or moving objects Muscular stress with no Repetitive Contact with Contact with lifting or moving objects movements no chemicals biological factors lifting Being assaulted by Slip Trip Fall Falls from height Exposure to person or persons environmental heat Exposure to Contact with Drowning or Insect spider bit or environmental cold electricity immersion sting Exposure to traumatic Work pressure Workplace Other mental event harassment or stresses bullying Vehicle accident Other If other please describe : What contributed to the incident /injury (What made the situation worse) Animals or insects Chemicals Electrical Water hydrants, equipment reticulation systems Moving plant Cutting sawing Gas mains, valves Sewerage mains, machinery etc valves etc Mobile plant small Small transport Other transport Powered portable – – cars, bikes etc equipment Hand tools Kitchen and Office equipment Pressure based domestic equipment equipment Sporting and Outdoor surfaces Weather Floor surfaces playground equipment Indoor environment Members of public / Other staff Children steps or stairs visitors members Ladders, mobile Other If other please describe: platforms and scaffolding Nature of injury: (Describe in your own words) Initial Medical treatment provided (if any) Hospitalisation Ambulance Number ________ – First Aid provided: Yes No Details of treatment – _________________________________________________ _________________________________________________ Body Location (select on picture) Name of person completing report _____________________ Signature____________________ Date of report_____/______/________ Name and signature of involved person if not the same as above_________________________________________________
Hitting object with body Being hit by moving/falling object Being hit by a person accidentally Being trapped or caught by moving equipment Being bitten by an animal Being exposed to vibrating machinery Exposure to noise Muscular stress while lifting or moving objects Muscular stress with no lifting or moving objects Repetitive movements no lifting Contact with chemicals Contact with biological factors Being assaulted by person or persons Slip Trip Fall Falls from height Exposure to environmental heat Exposure to environmental cold Contact with electricity Drowning or immersion Insect spider bit or sting Exposure to traumatic event Work pressure Workplace harassment or bullying Other mental stresses Vehicle accident Other If other please describe : What contributed to the incident /injury (What made the situation worse) Animals or insects Chemicals Electrical equipment Water hydrants, reticulation systems Moving plant Cutting sawing machinery Gas mains, valves etc Sewerage mains, valves etc Mobile plant – small Small transport – cars, bikes etc Other transport Powered portable equipment Hand tools Kitchen and domestic equipment Office equipment Pressure based equipment Sporting and playground equipment Outdoor surfaces Weather Floor surfaces Indoor environment steps or stairs Members of public / visitors Other staff members Children Ladders, mobile platforms and scaffolding Other If other please describe: Nature of injury: (Describe in your own words) Initial Medical treatment provided (if any) Hospitalisation – Ambulance Number ________ First Aid provided: Yes No – Details of treatment _________________________________________________ _________________________________________________ Body Location (select on picture) Name of person completing report _____________________ Signature____________________ Date of report_____/______/________ Name and signature of involved person if not the same as above_________________________________________________