What are the existing controls in place? (e.g. spill kits, bunding, clearing area pegged, PPE worn, machine guarding) Responsible Person Completion Corrective Actions Action Description Due Date and Role Date Control(s) put in place before and after the incident to Rectify, Contain or Remedy the situation Employee Type: (MRWA Employee OR Contractor OR Name: Job Title(s): Member of Public) (If applicable include Contractor name) Persons 1. 1. 1. Involved 2. 2. 2. 3. 3. 3. 4. 4. 4. What was the actual Insignificant Minor Moderate Major Catastrophic consequence? (Refer to Complete Incident Complete Incident 5 Why (MTI), ICAM or ICAM or equivalent ICAM or equivalent Appendix A below) Report Report equivalent investigation investigation investigation (LTI) What was the Potential Low Medium High Very High Outcome? Complete Incident 5 Why or equivalent ICAM or equivalent ICAM or equivalent Report investigation investigation investigation What is the Risk Rating Low Medium High Very High after controls are put in place? (Residual Risk) Yes No Report made by: Reference No: Date Report Made: / / INJURY DETAILS (only applicable if the incident resulted in personal injury): Fall from a height Exposure to (incl long term) How was the injury sustained? and Trips Contact with chemical or substance Vehicle incident Cuts, abrasions and lacerations (Mechanism of Injury) Musculoskeletal (sudden movement, sharp pains) Contact to heat and cold Repetitive movement with low muscle loading Contact with electricity Exposure to Mental Health Factors Insect bites and stings Exposure to vibration Unspecified mechanisms of injury or other Exposure to the Elements (UV, Cold) Treatment given & Name: Job Title: assessed by: Type of treatment given: None required First Aid Medical (Doctor/Hospital) Emergency Department Work Related Injury This is a work related injury This is a non-work related injury Bodily location of the Eye Shoulders and arms Internal organs injury: Face Hands and fingers Trunk (other than back and excl internal) Ear Back General and unspecified locations (Please select all that Neck Hips and legs apply) Head (other than the above) Feet and toes Comments:
What are the existing controls in place? (e.g. spill kits, bunding, clearing area pegged, PPE worn, machine guarding) Corrective Actions Action Description Responsible Person and Role Due Date Completion Date Control(s) put in place before and after the incident to Rectify, Contain or Remedy the situation Persons Involved Name: Job Title(s): Employee Type: (MRWA Employee OR Contractor OR Member of Public) (If applicable include Contractor name) 1. 2. 3. 4. 1. 2. 3. 4. 1. 2. 3. 4. What was the actual consequence? (Refer to Appendix A below) Insignificant Complete Incident Report Minor Complete Incident Report Moderate 5 Why (MTI), ICAM or equivalent investigation (LTI) Major ICAM or equivalent investigation Catastrophic ICAM or equivalent investigation What was the Potential Outcome? Low Complete Incident Report Medium 5 Why or equivalent investigation High ICAM or equivalent investigation Very High ICAM or equivalent investigation What is the Risk Rating after controls are put in place? (Residual Risk) Low Medium High Very High Yes No Report made by: Reference No: Date Report Made: / / INJURY DETAILS (only applicable if the incident resulted in personal injury): How was the injury sustained? (Mechanism of Injury) Fall from a height and Trips Vehicle incident Musculoskeletal (sudden movement, sharp pains) Repetitive movement with low muscle loading Exposure to Mental Health Factors Exposure to vibration Exposure to the Elements (UV, Cold) Exposure to (incl long term) Contact with chemical or substance Cuts, abrasions and lacerations Contact to heat and cold Contact with electricity Insect bites and stings Unspecified mechanisms of injury or other Treatment given & assessed by: Name: Job Title: Type of treatment given: None required First Aid Medical (Doctor/Hospital) Emergency Department Work Related Injury This is a work related injury This is a non-work related injury Bodily location of the injury: (Please select all that apply) Eye Face Ear Neck Head (other than the above) Shoulders and arms Hands and fingers Back Hips and legs Feet and toes Internal organs Trunk (other than back and excl internal) General and unspecified locations Comments:
Safety%20Health%20and%20Wellbeing%20-%20Form%20-%20Safety%20Health%20Incident%20Report.RCN-D16^23703957.DOCX