Vip Personnel Register Of Injury / Incident / Hazard & Investigation Form Page 2
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1
2
3Is a Workers Compensation Claim being made?
Part E – ACKNOWLEDGMENT OF INJURY / DATE OF ENTRY
Employee
Signature
Date
Employer
Signature
Date
Host Employer (if applicable)
Signature
Date
Part F – ACCIDENT / INCIDENT INVESTIGATION (to be completed for all reported incidents)
Contributing Factors to Consider
Environment
Person
Y
N
NA
Y
N
NA
Aware of the hazard
Adequate temperature conditions
Suitable for the task
Adequate lighting
Experienced at the task
Adequate working space
Familiar with the work area
Clear floor and walkways
Inducted to the site / task
Adequate housekeeping
Using appropriate PPE
Safe noise level
Job/Task
Y
N
NA Equipment
Y
N
NA
Was training provided
Correct equipment used
Supervision provided
Equipment in correct location
Job Analysis performed
Equipment guarded
Work procedures available
Preventative maintenance complete
Task not modified / changed
Equipment working properly
PPE provided
Equipment had not been modified
Other contributing factors?
Part G – RECOMMENDATIONS
Can the risk be eliminated? (circle Y or N)
Y
N
Why or How:
Can equipment or materials be substituted? (circle Y or N)
Y
N
Why or How:
Can engineering solutions be adopted? (circle Y or N)
Y
N
Why or How:
Can administrative controls be developed (circle Y or N)
Y
N
Why or How:
Is PPE required? (circle Y or N)
Y
N
Type:
Register of Injury / Incident / Hazard & Investigation Form
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