Incident Details: Event Title: Event Event Date: Event Time: Number: Injury Regulatory Notice Hazard Complaint Security Event Type: Journey Report (Select all as appropriate) Near Hit Environmental Impact Damage/Loss Incident Only Name of Injured Name of Person: Witness/s: Injured Person: Contractor Student Other: RMIT Staff If injury was sustained Campus: Bundoora City Brunswick Other: Location: (Building/Level/Room No.) Event Description: Immediate Actions Taken: Risk Rating (refer to Appendix 1 HSW Risk Score Matrix): – ACTUAL Risk Rating: Consequence: Likelihood: POTENTIAL Risk Rating: Consequence: Likelihood: Data Collection Mark “NA” in each section that is not applicable. Gather as many relevant facts as possible so as to understand the incident and the event leading up to it. Depending on the type of event, not all data collection questions will be applicable. What are the skills/licences required for the job and do they have these? What level of supervision is provided? What was their alertness at the time? Factors What were they doing at the time? How often do they do this (times/day, times/hour)? People Who else was involved?
Incident Details: Event Title: Event Date: Event Time: Event Number: Event Type: (Select all as appropriate) Injury Regulatory Notice Hazard Complaint Security Near Hit Environmental Impact Damage/Loss Journey Incident Report Only Name of Injured Person: Name of Witness/s: Injured Person: If injury was sustained RMIT Staff Contractor Student Other: Campus: City Bundoora Brunswick Other: Location: (Building/Level/Room No.) Event Description: Immediate Actions Taken: Risk Rating (refer to Appendix 1 – HSW Risk Score Matrix): ACTUAL Risk Rating: Consequence: Likelihood: POTENTIAL Risk Rating: Consequence: Likelihood: Data Collection Mark “NA” in each section that is not applicable. Gather as many relevant facts as possible so as to understand the incident and the event leading up to it. Depending on the type of event, not all data collection questions will be applicable. People Factors What are the skills/licences required for the job and do they have these? What level of supervision is provided? What was their alertness at the time? What were they doing at the time? How often do they do this (times/day, times/hour)? Who else was involved?
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