Form 040 Accident, Incident & Injury Report Use this form to report any workplace or journey accident, incident, near miss, injury or illness. Please note a separate WorkCover claim form is required if a claim is to be made. Immediately notify the General Manager in the event of a serious injury. The information on this form will be used only for the purposes of managing the incident, and mandatory reporting requirements. Please complete & return to the General Manager within 3 days of the incident.
Incident Date:	Time:	Date Reported:	Time:
Details of person injured or involved:
Surname	Given name:	DOB
Address	Male Female
Phone: (W)
Phone (H):	Signature of injured worker :	Date:
Employee ID	Student ID	Contractor / Other
Employment Status: (Full time, part-time, Permanent, Casual)	Position:	Date Started in Position:
School / Division	Supervisor:
Other Persons Involved / Witness:
Name:	Signature:	Date:	Phone:
Name:	Signature:	Date:	Phone:
Describe the Incident: (Describe the tasks being performed and the sequence of events) Immediate action taken:
Location of Incident:	Journey To / From Work
Incident Type:	Fatality	Hospitalisation Treatment	Medical Centre l	First Aid Treatment
Treatment
Nil Injury	Notification Only	Near Miss	Property Damage
Injury Allergy/reaction Amputation/degloving Bruise/contusion Burn Concussion Dislocation Electric shock Foreign body Fracture Heat exhaustion Insect bite Laceration Sprain/strain Multiple injuries Hernia Stress Hearing loss Skin disorder Respiratory Other specify	Body Location	Agent of Damage Vehicle Equipment/tool Explosion/implosion Chemical Electricity Radiation Thermal (heat or cold) Noise Biological Slip, trip or fall # Struck by falling object Stepping/striking object Needle or Sharp # Muscular – single event Muscular – repetitive / postural Workplace issues Other specify
#Special follow-up procedures are required for injuries involving contaminated needles or sharps and slips, trips and falls.

Management Review of Incident:
Contributing Factors: (Supervisor to Identify factors which contributed to the occurrence of this incident)
1. The Work Environment: (e.g. substandard conditions or work environment – physical conditions, visibility, ventilation, weather conditions, housekeeping etc.)
2. The Operation Procedure: (e.g. Substandard actions and methods – safe work procedure SWP, tools, equipment, machinery, instructions, use of safety devices, personal protective equipment PPE etc.)
3. Personal Factors: (Human factors such as fatigue, illness, lack of experience, over exertion, Judgement etc.)
4. Management factors: (substandard mgmt. – inadequate direction, supervision, training, equipment or procedures etc.)
5. Root Cause: (Identify the factors which had it not been present, the accident would not have occurred)
6. Slips, Trips Falls: (e.g.: footwear, surface conditions, weather conditions etc.)
Corrective Action Taken: (Identify those actions that you have or will take to prevent a recurrence of this incident)
Details of first aid administered:
Short Term Control Measures	Responsible Person	Completion Date
Long Term Control Measures	Responsible Person	Completion Date
Manager/Supervisor Comments: Name:_______________________ Signature:__________________________ Date:_________________
General Manager Comments: Report: Satisfactory Unsatisfactory Control Actions: Satisfactory Unsatisfactory Name:_______________________ Signature:__________________________ Date:_________________
JCU HSE Unit Comments: Report: Satisfactory Unsatisfactory Control Actions: Satisfactory Unsatisfactory Name:_______________________ Signature:__________________________ Date:_________________