HAZARD/INCIDENT/ACCIDENT REPORT FORM

Who uses this form?

Two people the worker and his or her supervisor (from the host employer).
Purpose?
When a hazard, incident or accident occurs, record what happened, what investigations occurred, and what was
done to prevent future injury or illness in relation to this incident or accident.
What should happen?
The host employer keeps the original and a copy is to be given to the labour-hire agency, to be kept in a file with the
host employers name on it.

PART A To be completed by employee

Name of employee:
Time of incident / accident:
Supervisor:

Renee Simmons

Date:

29/03/16

11:45
Nahla Kake

Work Area:

Pre-school room

1. Describe the hazard / detail what happened include area and task, equipment, tools and people involved.
During lunch time Renee was serving pasta to children on table 3 and slipped on the water spilled on the floor near Josh
chair.
She fell on her left hip and dropped the pasta bowl down on the floor.
She was in a lot of pain.
2. Possible solutions / how to prevent recurrence Do you have any suggestions for fixing the problem or preventing a repeat
Educators to be vigilant while serving food
Alert on water spills to children and other staff in the room
Spread a mat for water to be absorbed immediately after spill

PART B To be completed by supervisor

3. Results of investigation Determine whether the hazard is likely to cause an injury and explain what factors caused the event.
Water spill has caused Renee to slip and hurt her left hip which casued her a lot of pain.
Educators to communicate and be vigilant during food time

PART C To be completed by supervisor

4. Action taken Supervisor to identify actions to prevent injury or illness.
ACTION

RESPONSIBILITY

COMPLETION DATE

4.1

Spread mats to absorb water during spills

Educator

29/03/2016

4.2

Educate children on risks /injury casued by spills

Educator

30/3/2016

4.3

4.4

4.5

Feedback has been provided to person who reported the hazard / incident / accident.
Employee representative
(health and safety representative)
Business Manager

Kim Vincent

Date:

29/03/16

Sarah Dawson

Date:

29/03/16

WORKSAFE VICTORIA / SAFETY MANAGEMENT SYSTEMS GUIDE FOR LABOUR HIRE AGENCIES (2nd Edition, October 2005).

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