Accident and Incident Report Name/s of Persons Involved Basis of Employment Full Time Part Time Casual Volunteer Type of Employment Self Employed Administration Tradesperson Apprentice Member of Public Technical Professional Student Sub-Contractor Other Date DD slash MM slash YYYY Time Hours : Minutes AM PM AM/PM Weather Conditions Work Site Activities Being Carried OutDescription of Accident/IncidentRoot Cause of Accident/IncidentMechanism of Injury/Disease Falls, trips and slips Hitting objects with part of body Heat radiation and electricity Sound and pressure Body stressing Chemicals and other substance Biological factors Mental stress Other and unspecified mechanisms of injury Agency of Injury/Disease Machinery and (mainly) fixed plants Powered equipment, tools and appliances Chemicals and chemical products Mobile plant and transport Non-powered hand tools, appliances Materials and substances Animal, human and biological agencies Environmental agencies Other and unspecified agencies Name/s of Any Public Involved Names and Details of Persons Injured Including Any Medical TreatmentPlease complete the following by ticking the box that best describes the incident and provide an estimate of the lost time associated with the incidentIs the incident a Notifiable Incident (NI)? Yes No Notifiable Incidents are those that involve the death of a person, a serious injury or illness of a person, or a dangerous incident and in accordance with the QLD WHS Act 2011 requires the completion and submission of a Queensland Government FORM 3 V1.10.11 immediately to whsq.aaa@justice.qld.gov.auWhat is the estimated quantity of days/shifts lost as a result of this incident? Is the incident a Medically Treated Injury (MTI)? Yes No Medically Treated Injuries are those that involve work-related injuries/diseases where medical treatment was required that result in the loss of less than a full shiftWhat is the estimated quantity of hours lost as a result of this incident? Is the incident a First Aid Injury (FAI)? Yes No First Aid Injuries / Minor Injuries are those injuries treated either by a first aid officer, self or medical practitioner (not meeting the criteria for a MTI) that are also recorded in company’s official injury register or other recording system.Is the incident a Near Miss (NM)? Yes No Near misses are those that involve unplanned incidents that occurred at the workplace which, although not resulting in any injury or disease, had the potential to do so.If body injuries were sustained in the incident, please identify the areas:What action could have been taken to prevent the accident/incident?Signature of person involvedDate DD slash MM slash YYYY Action to be taken to prevent re-occurenceSignature of managerDate DD slash MM slash YYYY Date discussed with those involved DD slash MM slash YYYY Tool Box Meeting No. Date discussed with staff DD slash MM slash YYYY Signature of Those Staff BelowName(Required) Signature(Required)Name SignatureName Signature 65469
