BSBWHS401 Assessment 2: Incident Report, Training Plan and Agreement

This document presents a completed incident report, aligned with the BSBWHS401 unit requirements. The report details an incident involving an employee injured by a conveyor belt, including witness information, nature of the injury, and treatment administered. The report covers the incident's specifics, including date, time, and location, alongside details of the injured person and witness. It also incorporates sections for the employer to complete, such as whether the injured person stopped work, incident investigation comments, risk assessment, and actions to prevent recurrence. Furthermore, the assessment brief highlights the need for a structured training plan using coaching or mentoring to address workplace health and safety gaps, along with the importance of accurate record-keeping. The report also includes a section for review comments from the WHS committee and relevant managers. This assignment provides a practical example of how to document workplace incidents and assess training needs in line with WHS regulations.

Incident / injury report form Appendix 3
Please print clearly and tick the correct box
Status:  Employee  Contractor  Other
Outcome:  Near miss  Injury
1. DETAILS OF INJURED PERSON
Name: A. David____________________________________ Phone: (H) (W)
Address:46/1, Russels road__________________________________ Sex:  Male  F
________________________________________________________ Date of birth:10.7.1975_________________
________________________________________________________ Position:Experienced staff_______________
Experience in the job:11 years________________________________ (years/months)
Start time:10.2.2008________________________________________  am  pm
Work arrangement:  Casual  Full-time  Part-time  Other
2. DETAILS OF INCIDENT
Date:10.5.2019_______________ Time:12 pm, afternoon__________________
Location:Factory or the manufacturing Unit_________________________________________________________
Describe what happened and how: the person got seriously affected due to some activity in the conviour belt.____
___________________________________________________________________________________________
___________________________________________________________________________________________
3. DETAILS OF WITNESSES
Name: A. Swann__________________________________________ Phone: (H)_____________ (W)___________
Address: 28/2 Russel Street_____________________________________________________________________
4. DETAILS OF INJURY
Nature of injury (eg burn, cut, sprain) Accident in legs due to conveyor belt activity__________________________
Cause of injury (eg fall, grabbed by person) Convoyer belt activity_______________________________________
Location on body (eg back, left forearm)legs, both legs________________________________________________
Agency (eg lounge chair, another person, hot water)another person______________________________________
5. TREATMENT ADMINISTERED
First Aid given  Yes  No
First Aider name:______________________________________________________________________________
Assessment 2, LA number LA019751, Unit code BSBWHS401, Edition number 1
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© New South Wales Technical and Further Education Commission, 2015 (TAFE NSW – WSI), Archive version 1, July 2015

Treatment: Intensive treatment in the hospital_______________________________________________________
Referred to:ICU care Unit_______________________________________________________________________
Assessment 2, LA number LA019751, Unit code BSBWHS401, Edition number 1
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© New South Wales Technical and Further Education Commission, 2015 (TAFE NSW – WSI), Archive version 1, July 2015

SECTION 6-9 MUST BE COMPLETED BY EMPLOYER
6. DID THE INJURED PERSON STOP WORK ?
 Yes  No If yes, state date:_____________________________________ Time:___________________
Outcome:
 Treated by doctor  Hospitalised  Workers compensation claim
 Returned to normal work  Alternative duties  Rehabilitation
7. INCIDENT INVESTIGATION (comments to include causal factors):
8. RISK ASSESSMENT
Likelihood of recurrence:________________________________________________________________________
Severity of outcome:___________________________________________________________________________
Level of risk:
9. ACTIONS TO PREVENT RECURRENCE
Action By whom By when Date completed
10. ACTIONS COMPLETED
Signed (Manager):________________________________________________ Title:
Date:
 Feedback to person involved Date:________________________
11. REVIEW COMMENTS
WHS committee / staff meeting:__________________________________________________________________
TAFE NSW – Western Sydney Region
Created: 4/02/2013
Version: 1.0
14037629912904592427.docx
Modified: 30/08/2024
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Reviewed by site Manager (signed):__________________________________ Date:________________________
Reviewed by Health & Safety Rep.(signed):____________________________ Date:________________________
TAFE NSW – Western Sydney Region
Created: 4/02/2013
Version: 1.0
14037629912904592427.docx
Modified: 30/08/2024
Page 4 of 4