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Incident Report
Incident Report
Date report is being made: PART A: This form is to be used for ALL accidents, or near misses, whether an injury occurred or not ACCIDENT / INCIDENT REPORT FORM TO BE COMPLETED BY PERSON INVOLVED (or by supervisor or if person is incapacitated then by nearest relative) Please complete within 24 hours of the accident. If the accident caused, or could have caused, serious injury or property damage, please contact SAGHS on 08 8272 4222 immediately.
Are you currently employed? Name of employer: Address: Will you require time off work? What type of event is this? Where did it occur?
unknown
Approximately how long will you be off work? Medical YES Date Reported NO
Have you already reported the accident / incident / near miss? If YES, who did you report it to? Name
Trunk
Neck Hip Chest Stomach Groin Back Multiple
Internal
Heart Lungs Systemic
Arm
Left Right Shoulder Upper Arm Elbow Forearm Wrist
Hand
Left Right Thumb Fingers
Leg
Left Right Knee Lower Leg Ankle Thigh
Foot
Left Right Great Toe Other Toes
Accident / Incident Report & Investigation Form Version 1: 2004 Date Printed: 6/04/2013
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Bruise Laceration Hearing Loss Strain Scald Fracture Amputation Foreign Body Hernia Rash Concussion Bite Minor Cuts Allergy Aggravation of previous injury or medical condition, or other injury not already specified. (describe)
Signed: PART B:
Date:
INVESTIGATION FORM TO BE COMPLETED BY THE SUPERVISOR AND/OR DELEGATED OFFICER WITHIN 48 HRS OF NOTIFICATION
IMPORTANT: This part of the process is designed to prevent recurrences
Moderate
(eg medical attention)
High
(eg ambulance or other emergency services)
Severe
(eg death or severe disablement)
Accident / Incident Report & Investigation Form Version 1: 2004 Date Printed: 6/04/2013
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REHABILITATION
Is required Is not required Unknown as yet Time Off Work Required.
5: ADMINISTRATION
Investigation undertaken by supervisor or delegated officer Print name: Signature: A copy of this report must be provided to the person making the report. The original must be retained by SAGHS copy provided to person making report Date Date investigation completed:
Accident / Incident Report & Investigation Form Version 1: 2004 Date Printed: 6/04/2013
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