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Overview
Complete
Incident / Hazard Report Form
05 Jan 2021 / SafetyCulture Staff
Inspection score
42.86%
Failed items
4
Created actions
1
Date and Time Reported

5th Jan, 2021

3:17 PM PST

Hazard Reported by
SafetyCulture Staff
Contact Number of Person Reporting Hazard
12345678
Location of Hazard
Wollongong NSW 2500, Australia (-34.4278121, 150.8930607)
Specific Location (room or area within the building, compound, or facility)
Wollongong Construction Site - Northeast Area
Failed items
4
Incident / Hazard / Incident Details
Incident / Hazard Type
Incident Occurred
Photos
Incident / Hazard / Incident Details
If Incident Occurred,
With Injury
Photos
Incident / Hazard / Injury Details
Level of Treatment Needed
Lost Time Injury
Photos
Corrective Actions / Risk Assessment
Level of Risk
High
Actions
1
Incident / Hazard
3
Incident Details
2
Incident / Hazard Type
Incident Occurred
Photos
If Incident Occurred,
With Injury
Photos
Description of Incident / Hazard
Field worker fell from a great height without proper support
Injury Details
1
Only Complete for Incident With Injury
Name of Injured Person
Rick Injury
Contact Number of Injured Person
87654321
Nature of Injury
Other
If Other, please describe injury
spinal cord injury and concussion
Location of Injury on Body
spine and head
Specific Task Being Performed at Time of Injury
attaching a steel bar
Level of Treatment Needed
Lost Time Injury
Photos
Name of First Aider or Treatment Provider
Treatment Provider A
Description of Treatment Provided
Injured person placed in intensive care unit
Corrective Actions
1
1
42.86%
Contributing Factors
42.86%

Lack of/Inadequate Equipment/Machinery

Lack of/Inadequate Procedures/Instructions

Lack of/Inadequate Management/Supervision

Lack of/Inadequate Management System

Lack of/Inadequate Employee/Worker Training

Inappropriate/Inadequate Work Environment

Inappropriate Actions and/or Behavior

Other
Unanswered
Cause of Incident/Hazard
Lack of proper support for working at heights
Risk Assessment
1
Consequence
Severe
Likelihood
Almost Certain
Determining Level of Risk
Consequence - Severe, Likelihood - Almost Certain
If Option Selected Previously is Red, Level of Risk is High.
If Option Selected Previously is Yellow, Level of Risk is Medium.
If Option Selected Previously is Green, Level of Risk is Low.
Level of Risk
High
If Level of Risk is High or Medium, at least 1 corrective action must be completed.
Corrective Actions
Corrective Actions / Corrective Actions 1
1
Control Type
Isolation/Stop Use
Photos
Please click "Action" icon below
Corrective Action Created
Actions
In progress
Close area where incident occurred.
After creating an action, set the date and time the corrective action has to be completed and assign it to a user in your organization.
Final Page
To whom should this hazard report form be sent to?
HSE Manager
Signature of Person Reporting Hazard
Henrietta Hazard
5th Jan, 2021 3:36 PM PST
Media summary
4 Media files