Location on body (please circle and specify): How injury occurred (e.g. fall, grabbed by person, muscular stress): What caused the injury (e.g. furniture, another person, hot water): Treatment administered if required: Yes No Treatment: Referral required: Yes No Who to: First aid attendant (Print Name): Signature: THE FOLLOWING SECTIONS ARE TO BE COMPLETED BY THE SAFETY OFFICER Incident or accident investigation:   Did the incident occur as part of the involved person’s normal activities? Yes No N/A   Did equipment contribute? Yes No N/A   Was the equipment used designed for activity? Yes No N/A   Was the equipment properly maintained? Yes No N/A   Did the equipment fail? Yes No N/A   Had a risk assessment been undertaken? Yes No N/A    Did safety instructions accompany activity? Yes No N/A    Are there documented safe work procedures (SWP) for activity? Yes No N/A   Were these Safe Work Procedures followed? Yes No N/A   Was appropriate PPE used? Yes No N/A   Was the involved person trained in this activity? Yes No N/A   Did a known behaviour problem contribute? Yes No N/A   Was there a known behaviour management plan? Yes No N/A   Was it followed? Yes No N/A   Did poor housekeeping contribute? Yes No N/A   Did the work environment contribute? Yes No N/A After reviewing the above prompts and through interview/site visits what is the identified cause(s):
Location on body (please circle and specify): How injury occurred (e.g. fall, grabbed by person, muscular stress): What caused the injury (e.g. furniture, another person, hot water): Treatment administered if required: Yes No Treatment: Referral required: Yes No Who to: First aid attendant (Print Name): Signature: THE FOLLOWING SECTIONS ARE TO BE COMPLETED BY THE SAFETY OFFICER Incident or accident investigation: Did the incident occur as part of the involved person’s normal activities? Yes  No  N/A Did equipment contribute? Yes  No  N/A Was the equipment used designed for activity? Yes  No  N/A Was the equipment properly maintained? Yes  No  N/A Did the equipment fail? Yes  No  N/A Had a risk assessment been undertaken? Yes  No  N/A Did safety instructions accompany activity? Yes  No  N/A  Are there documented safe work procedures (SWP) for activity? Yes  No  N/A  Were these Safe Work Procedures followed? Yes  No  N/A Was appropriate PPE used? Yes  No  N/A Was the involved person trained in this activity? Yes  No  N/A Did a known behaviour problem contribute? Yes  No  N/A Was there a known behaviour management plan? Yes  No  N/A Was it followed? Yes  No  N/A Did poor housekeeping contribute? Yes  No  N/A Did the work environment contribute? Yes  No  N/A After reviewing the above prompts and through interview/site visits what is the identified cause(s):
WHS-Policy.docx