EMPLOYEE NEAR MISS/ACCIDENT/ INJURY/HAZARD REPORT

This report relates to: Near miss Accident Illness Injury First Aid Medical treatment
Lost work time Hazard report Property damage

Name of person injured/involved:

Anggi Pradita Birth date: 01-01-1989

Incident date: 15 May 2024 Time of incident: 12:30 Date Reported: 15 May 2024

Name of person reporting: Andy Warhol

Description of Incident/Accident: Employee suffered a superficial graze on the hand while working in the
kitchen.

Any Contributing factors or Hazard: : Sharp edge on kitchen equipment.

Description of Injury: : Superficial graze with a small amount of blood.

First Aid Administered by: : Kitchen Manager

Describe first aid administered: :
Cleaned the wound with soap and water, applied antiseptic, and covered with a waterproof ban

Was an ambulance required? Yes No

Where was the injured person taken? : Hospital
Who accompanied the person? : Kitchen Manager
Emergency contact notified by: :
Kitchen Managee Time notified: Not Required

Employer notified by: : Kitchen Manager Time Notified: : 13:00

Follow Up Action Required: (Corrective action needed for prevention)

Timeframe Person responsible

What action needs to be taken

Ensure all sharp edges on kitchen equipment are properly

1 week Kitchen Manager
covered or repaired to prevent further injuries.

Reinforce training on proper handling of equipment to

1 week Kitchen Manager
minimize the risk of accidents.
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Follow-up report completed by: Andy Warhol Position: Kitchen Manager Signature:
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Date: 15 May 2024
Copy of report to: Employer In WHS Register WHS Insurance
Report completed by: Andy Warhol Position: Kitchen Manager Signature:
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Date: 15 May 2024