INCIDENT / INJURY REPORT

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 To be completed for ALL incidents, injuries, accidents and near misses
Status: Date: 23/02/2022
Employee Visitor Contractor Volunteer
Client Resident Student

1. Details of injured person:

Surname: Gayle Phone: (h) (w)
First Name: Chris Sex: M F
Address: Sydney Date of Birth:
1st Language:
Experience in job:
0-3 months 3-5 years Casual Full-time
4-12 month 5 years plus Permanent P/T Other
1-2 years
2. Details of witnesses:
Name: Ram Sharma Phone: (h) (w)
Address: Sydney Australia
Name: Radha Krishna Phone: (h) (w)
Address: Sydney Australia
3. Details of incident or accident:
Date: 23/02/2022 Time of injury: 9:30 am
Activity engaged in: management
Location of incident / accident: Across a walkway in the corridor
Describe how and what happened (please give full details & include a diagram, if appropriate. Use a separate sheet if necessary. Please include
car registration number if reporting a Motor Vehicle Accident):

A worker tripped over a power cord that was strewn over a hallway walkway. With their hands outstretched in front of them,
the worker collapsed to the ground. Although there was no blood on the scene, the worker's left hand and wrist were
extremely uncomfortable and swollen.

4. Details of injury (the assistance of a supervisor may be required to complete this section)
Nature of injury / illness (e.g. burn, sprain, cut etc): Broken Wrist

How (e.g. fall, grabbed by person, muscular stress): fall in the corridor

Location on body (e.g. back, right thumb, left arm etc): left wrist

What (e.g. furniture, another person, hot water): tripped over a power cable and fall in the corridor

5. Treatment administered:

First aid officer put some ice to the injured area and taken to the emergency department of the nearest hospital for the
further treatment.
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This page to be completed by the Senior Staff Member on duty

6. Did the injured person stop work:
Yes No If yes, state date: Time:
Outcome:1
Treated by Doctor Lodged Workers Comp Claim Referred to RTW Coordinator
OHS Authority notified Returned to normal duties Referred to OHS Coordinator &/or
Hospitalised Returned to alternative duties OHS Committee

7. Incident or accident investigation

(Comments to include identified causal factors):
The health and safety representative (HSR) went to the accident location and taped the power cord to the floor to prevent
any further mishaps.

Name & Signature of Supervisor: Date: 24/02/2022

8. Remedial actions:
Conduct task analysis
Conduct hazard systems audit
Develop/ review tasks procedures
Improve work environment
Review OH&S policy/programs
Replace equipment / tools
Improve work organization
Develop and/or provide training
Re-instruct persons involved
Improve resident /staff skills mix
Provide debriefing and/or counselling
Request maintenance
Improve personal protection
Improve work congestion/
housekeeping
Investigate safer alternatives
Other (specify)
Improve design / construction /
guarding
Add to inspection program
Improve communication / reporting
procedures
Improve security
Temporarily relocate employees
involved
Falls Prevention Assessment
Request MSDS (Materials Safety
Data Sheet)

What, in your own words, has been implemented or planned to prevent recurrence:

From the incident, the supervisor improved the work organization and requested the maintenance of the all the
possible place to reduce the accident in the workplace,

9. Remedial actions completed:

Signed (Supervisor): Title: supervisor Date:23/02/2022
10. Review comments
H.R. Manager: be careful about the surrounding situations to reduce the possible accident and improve the possible
accident situation in the workplace
OHS Committee Meeting: Maintain or replace the possible risk factors in the workplace.

Reviewed by CEO / OHS Coordinator (Signed): Date: 23/02/2022