Incident Report Form for Workplace Injury or Damage

This incident report form is to be completed within 12 hours of the incident to ensure appropriate action is initiated. It includes personal details, incident details, injury/damage details, medical treatment, witnesses, and an action plan.

Incident report
Incident report
Note: All sections of this form are to be completed. All incidents shall be advised within 12 hours of the
incident to ensure appropriate action is initiated.
Personal details
Family name: < Please fill > First name: < Please fill >
Contact Phone No: (w) < Please fill > (h - if injured) < Please fill >
Occupation: System IT Gender:  M  F
Staff employment status:
 Full-time  Part-time  Casual
 Contractor  Visitor
Division/Department: IT
Incident details
Date of incident: 06/06/2018 Time of incident: 07:00:00 AM
Location where incident occurred:
Melbourne
Briefly describe what happened:
There were many new computers in the office and in the cubicles of the staff members’ in
the office. The power extension and network cables became loose and were lying on the
floor of the hallway and desks. I was just walking on the corridor. One of the cable was
loose and I had put my hand on an open cable on it and got cut with it and that very
moment my head got hit on a chair. My colleague push me backward by hitting with some
rubber material and I was lying unconscious for some time. My head has wound and I was
feeling light headed, dizzy and headache. This has led to a serious incident.

This incident resulted in:
 Injury  No injury  Near miss
 Property damage  Hazard identified
The incident was reported to (Supervisor):
Name of Supervisor: < Please fill > Date: 06/06/2018
Are there any Sensitive issues than need to be considered?
The issue that has to consider is the part of the body has got senseless. One part of the
body is not responding.
Injury/damage details
If an injury was sustained, what part of the body was affected or if damage to property
occurred what was damaged?
My right hand and right leg has completely become senseless. I am unable to feel any
response in my right part of the body.
Medical treatment
If MEDICAL EXPENSES or LOST TIME is incurred, a ‘Workers Compensation Claim form’
must be completed and forwarded to WHSW & IM Services ‘as soon as possible’.
Do you intend to seek medical treatment?  Yes  No
Do you intend to lodge a claim for workers compensation?  Yes  No
Has any time been lost from work?
(More than 1 complete shift)  Yes  No
If so, have you returned to work?  Yes  No
Have/will medical expenses been incurred?
 Yes No
 Uncertain at this time
Were there witnesses?
If so, name of witness:
< Please fill >
Contact phone number:
< Please fill >

Employee signature:
< Please fill >
Date:
06/06/2018
If a medical certificate has been provided please send to: Fax xxxx xxxx or email: [e-mail]

Describe in detail what occurred
It is the responsibility of the supervisor/line manager to complete this section in
consultation with the injured staff member.
Please describe the events and contributing factors that led to the incident:
The incident took inside the office where one of the staff member was walking through
the corridor and suddenly got in contact with the loose cable. The staff member did not
see through it and came in contact with the cable due to which sudden shock has affected
his right part of the body. It seems that the right part has become senseless. It is not
responding to any kind of feeling. It might happen the some part of the brain has got
affected due to which the sense has gone and is not responding now.
How could this be prevented from happening again?
The Supervisor/Line Manager is to complete this section in consultation with the injured
staff member and the Health & Safety Representative (if applicable)
Suggestions to avoid recurrence of this incident/accident:
The power extension and network cable that are spread on the floor of the hallway should
be fixed to the walls and the computer should be set properly and making sure that the
connection are not kept loose.
Name of health and safety representative, if consulted:
< Please fill >
Action plan
Note: From the previous section, list the actions required to prevent this happening again.

Action to prevent recurrence
(Do not leave blank)
Person
responsible
for action
Action
taken
Sign-off completed
(signature required)
Fitting of Cables to walls IT faculty Fitted Cables to
walls
< Please fill >
Aware the staff members about the
cable
IT executive Provided with
template
< Please fill >
 Referred to Line Manager  Placed issue on local action plan
 Consulted employees  Advised Senior Manager
 Advised WHSW Services  CSR raised, referred to FMU
Feedback provided to affected person on outcome
Is rehabilitation required?
 Yes
 No
 Rehabilitation consultant advised
Date: 06/06/2018
Name of Supervisor:
< Please fill >
Contact Phone Number: < Please fill >
Signed:
< Please fill >
Date: 06/06/2018