INCIDENT REPORT FORM

Date of Incident: Time of Incident: AFLs 9s Program:

Completed By: Position: Other Staff Involved:

Date of Incident Notification: Time of Incident Notification: Name of Person/s Notified:

Full Name: Gender: Male Female

Address:
Suburb: Date of Birth: _____/_____/_____
Phone (Home): Phone (Mobile):

General Incident Near Miss Alleged Incident

Equipment Malfunction Property Damage / Loss Environmental (Spills / Leaks)
Bomb Threat / Explosion / Fire Theft Accident Without Injury
Security Breach Threat or Act of Violence Media Coverage
Other: ____________________

Description of Incident:

Awareness Work on Live Equipment Failure to Use PPE

Unsafe Action Unsafe Position Improper Tools
Unsafe / Defective Equipment Unsafe Work Surface Improper Use of Equipment
Failure to Secure or Warn Housekeeping No Risk Assessment
Lack of Training Ineffective Lock Out Lack of Knowledge
Lack of Supervision Lack of Resources Other: ____________________

Description of causes, please provide detail:

Description of action taken so far:

Is the area now safe? Yes No N/A

If no, has the area been placed under supervision? Yes No
Has the issue been resolved? Yes No N/A
If No, what action will be taken and by whom?
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If the Incident was a Near Miss, what is the worst possible outcome (if the Near Miss) had eventuated?

What are the potential improvement opportunities (to prevent a reoccurrence)?

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Incident Review to be completed by HSO or Centre/Program Manager

What took place? (Think prior to the incident, during the incident and after the incident)

What was the immediate action you (as HSO or Manager) took after being notified of the incident?

What main findings were there?

Can the risk be eliminated/reduced? How?

What could have been the outcome if staff were not present?

Has this incident happened before? If it is a repeat incident, what has contributed to it occurring again?

Is re-training required for the staff involved? What is required? How will the training be undertaken?

Is this incident notifiable to Worksafe? If yes, include Worksafe notification reference number.

Have you undertaken preventative/corrective actions? What actions are you implementing?

Due Diligence Yes No

Is a claim likely to occur from this incident?

Did the incident have the potential to be more serious? (eg. major incident, critical incident)

Did the incident involve major plant malfunction resulting in extended disruption to operations?

Was equipment failure a contributing factor in the incident?

Was there/or the potential for environmental damage? (eg. Waterways, sewers, trees, , etc)

Was there damage to YMCA or third party assets? (eg. Equipment, building, vehicle, etc)

If you answered Yes to any of the above Due Diligence questions, an investigation is to be completed.

Review Completed By: Signature:

Please ensure all relevant risk assessments, procedures and work instructions have been reviewed.