Accident and Incident Report

Injured / ill worker’s details

First name: Ulio Last name: Fabrizio Date of 22 May

birth: 1984
Position: Chef Department Restaurant Kitchen

Worker’s 191 Marina Quays Boulevard, Queensland

Address
Manager/supervisor’s name: Phil Jones

Injury or illness details

Date of March 19, 2024 Time of 12:35pm am/pm

injury/illness: injury/illness:
Nature of injury/illness:
Cut on the forefinger whilst doing steak preps

Bodily location of injury/illness (include symptoms for illnesses):

Index finger, excessive bleeding after a deep cut

Location at time of injury:

Kitchen

How was the injury/illness sustained (cause of injury /illness):

Chef engaging in conversation with the venue manager whilst multitasking and partaking his Mise en place

Was any plant, equipment, substance or object involved in the injury/ illness? If yes, please provide
details:

Accident and Incident Report

Sharp steak knife was being use to prepare steaks for service.

Witnesses

Were there any witnesses to the injury/illness?

Yes or no. If yes, please list name and contact number for each witness:
Name: Chef - Milan White Contact: 0421 000 0000
Name: Dish washer - Desmond Blake Contact: 0401 388 0295
Name: Contact:
Name: Contact:
Name: Contact:

Follow-up

Has the injury been reported to the worker’s supervisor? Yes or No: Yes
Was any treatment provided? Yes or no. If yes, please provide details:
Basic first aid bandage and gauze used to disinfect and cover the wound

Did the injured worker return to work following the injury/illness? If yes, please provide Yes
details:
The Chef returned to work the next day after the beleding had completely stopped with a bandage and a
cover to ensure no cross contamination with meals.

Details of person making this entry

First name: Phil Last name: Jones

Position: Venue Manager Department/team: Restaurant Services
Signature: Phil Jones Date: 20 Mar 2024

If you are not the injured worker, did you witness the injury/illness? Yes or no No

TO BE COMPLETED BY MANAGER/SUPERVISOR OF INJURED / ILL WORKER

Has an investigation into the incident been conducted? If yes, by whom? Yes, Venue Manger

Accident and Incident Report

 What controls have been implemented to ensure the incident doesn’t happen again?
Ensuring that a debrief on basics of avoiding multitasking when handling sharp objects was put in
place

Employer confirmation

I, Phil Jones (print name), of

Righteous Inn Restaurant (insert company name),

Hereby confirm receipt of this notification.

Signature: Phil Jones Date: 20 Mar 2024

Accident and Incident Report