MyHR WHS: Health and Safety Incident
MyHR WHS: Health and Safety IncidentData Collection FormPrivacy statement: The Department of Education (DoE) is collecting personal health and safety incident information on this form in accordance with the Work Health and Safety Act 2011 (Qld), the Work Health and Safety Regulation 2011 (Qld), and/or the Electrical Safety Regulation 2002 (Qld). The information collected may be disclosed to third parties, including the Government Superannuation Office, Australian Tax Office, Workplace Health and Safety Queensland, Electrical Safety Office (Qld), WorkCover Queensland, industrial organisations, or other entities in accordance with, or where requested by law or industrial instrument. The information collected on this form will be manually entered into the MyHR Workplace Health and Safety Solution for review by a supervisor. When to use this formThis form is for data collection purposes only and is not a required form to complete. It is to be used to gather information for later entry into the MyHR WHS – Incident module. It is mandatory to use MyHR WHS for recording health, safety and wellbeing incidents. It can be used: when an incident occurs away from the workplace e.g. camps, fetes, sports for staff working out of hours or with limited access computers e.g. cleaners, grounds maintenance stafffor visitors or contractorsto implement a local protocol where data entered into MyHR WHS by a limited number of staffduring system outage.Every effort is to be made to verbally report an incident to the school/workplace on the day of the incident to enable a record to be made in MyHR WHS no later than the next business day The Health, Safety and Wellbeing Incident Management procedure is to be followed. left84234Notifiable incidents must be reported to WHSQ. Notifiable incidents include:deathserious injury or illness e.g. amputation, head injury, spinal injury, hospital admissiondangerous incidents e.g. electric shock, explosion, fire, release of hazardous substance. How to report: Immediately contact WHSQ by phone: 1300 362 128 to notify them of the incident.WHSQ should provide a reference number for your call. Note that you contacted WHSQ and record the reference number in the ‘immediate actions taken’ section of this form. Complete all relevant information within this form and ensure the data is entered into MyHR WHS as soon as possible. Not sure? Check the full definitions within the procedure, contact your Regional Health and Safety Consultant or phone WHSQ.00Notifiable incidents must be reported to WHSQ. Notifiable incidents include:deathserious injury or illness e.g. amputation, head injury, spinal injury, hospital admissiondangerous incidents e.g. electric shock, explosion, fire, release of hazardous substance. How to report: Immediately contact WHSQ by phone: 1300 362 128 to notify them of the incident.WHSQ should provide a reference number for your call. Note that you contacted WHSQ and record the reference number in the ‘immediate actions taken’ section of this form. Complete all relevant information within this form and ensure the data is entered into MyHR WHS as soon as possible. Not sure? Check the full definitions within the procedure, contact your Regional Health and Safety Consultant or phone WHSQ.How to use this form This cover page is for information and advice.Pages 1-3 are to be completed as they record the details of the incident and the injured person.If relevant, complete a sub form (page 4) for each ‘incident type’; electrical, security threat, motor vehicle, fire, environmental or near miss. Each incident type has its own ‘sub form’.e.g. for an injury sustained while driving a motor vehicle – complete pages 1-3 (which includes the ‘injury/illness’ details) and the ‘motor vehicle’ sub formif more than one person sustained an ‘injury/illness’ as a result of the same incident, fill in a separate injury/illness form (pages 2-3) for each person. You do not need to complete separate forms for the incident (page 1)Record all available information.Check that all mandatory fiends, e.g. those marked with *, are completed. Give the completed form to your supervisor or administration to enable data entry into MyHR WHS OR enter into MyHR WHS yourself on return to the workplace. This form can be scanned and attached to the MyHR WHS incident record within investigation screens.This paper form is to be retained for 12 months at the workplace.right7772INCIDENT DETAILS00INCIDENT DETAILS*Incident date: ______/______/______Incident time: (24 hour HH:MM) ______:______If the incident occurred at your school or base location, you need ONLY complete the School/base location field. If the incident did not occur at your school/base location, then you need to complete the School/base location field and the Other incident location field. *School/base location: __________________________________________________________________________Other incident location (address details): _________________________________________________________________________________________________________________________________________________________*Summary of incident (approx. 20 words): _________________________________________________________________________________________________________________________________________________________Detailed description of incident: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________*Immediate action taken (including any lockdown or evacuation, parents contacted, first aid administered, ambulance called, doctor/out patients or hospitalisation, WHSQ notified and reference number, what was done to prevent this or something similar from happening again, etc.): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________left14453INCIDENT TYPES00INCIDENT TYPESInstructions: select one or more incident types.Incident types FORMCHECKBOX injury/illness FORMCHECKBOX electrical FORMCHECKBOX security threat FORMCHECKBOX motor vehicle FORMCHECKBOX fire FORMCHECKBOX environmental FORMCHECKBOX property/plant/equipment FORMCHECKBOX near missIf ‘electrical’ or ‘environmental’ or ‘fire’ or ‘property/plant/equipment’ is selected as incident type, the question ‘Was this a dangerous incident as defined under legislation?’ must be answered. Was this a dangerous incident as defined under legislation? FORMCHECKBOX Yes FORMCHECKBOX NoIf you are unsure, refer to the Definitions of Dangerous Incidents and Electrical Incidents page on the WorkSafe website. left5715REPORTING DETAILS00REPORTING DETAILS *Reported date: ______/______/______*Reported by: (at least one ‘reported by’ field must be populated) FORMCHECKBOX Staff member (name): _________________________________ Base location: ______________________________ FORMCHECKBOX Student (name): _____________________________________ Base location: _______________________________ FORMCHECKBOX Other person (name): _________________________________ Base location: _______________________________Other person’s contact details if known: _________________________________________________________________Name of reviewer: __________________________________________________________________________________Name of person completing this form: __________________________________________________________________0-635INJURY/ILLNESS DETAILS00INJURY/ILLNESS DETAILS*Injured person’s details: FORMCHECKBOX Staff member (name): _________________________________ Base location: ______________________________ FORMCHECKBOX Student (name): _____________________________________ Base location: _______________________________ FORMCHECKBOX Other person (name): _________________________________ Base location: _______________________________Type of other person: FORMCHECKBOX Client FORMCHECKBOX Contractor FORMCHECKBOX Parent FORMCHECKBOX Visitor FORMCHECKBOX Volunteer FORMCHECKBOX Other: _________________________Other person’s contact details if known: ________________________________________________________________Injury details* Injury/illness classification – select one of the following FORMCHECKBOX Serious injury – fatality FORMCHECKBOX Serious injury – non-fatality FORMCHECKBOX Work-caused illness FORMCHECKBOX Psychological illness FORMCHECKBOX Bodily injury FORMCHECKBOX Minor injury or incident Use the reference lists below to complete the body location details and the nature of injury/illness details*Bodily location (reference list) *Nature of injury/illness (reference list)FaceHeadEyesEarsNoseTooth/teethNeckArmsElbowsShouldersHandsWristsBackMouthChestFingersAbdomen/stomachHipsLegsGroin areaKneesFoot/feetToesAnklesSkinRespiratory systemInternal organsSpinePsychological conditionOther e.g. fainting __________________Ache/painCut/lacerationAmputationBite/stingBruising/crushingDislocationSprain/strainBurn/scaldFractureInfection/diseaseHearing loss/deafnessPsychological stressAllergySkin irritation/dermatitisHeat/cold stressPoisoningRespiratoryPuncture/needle stickWeld flashEye disorderForeign bodyHead injuryInternal injuryHeart or circulatory conditionOther e.g. fainting __________________Injury 1Body location: __________________________________ Nature of injury/illness: ________________________________If more than one injury or body location, complete below. Injury 2Body location: __________________________________ Nature of injury/illness: ________________________________Injury 3Body location: __________________________________ Nature of injury/illness: ________________________________* Cause of injury/illness – select one of the following FORMCHECKBOX Slip, trip or fall FORMCHECKBOX Contact with, or striking against object FORMCHECKBOX Vibration FORMCHECKBOX Struck by falling or moving object FORMCHECKBOX Noise FORMCHECKBOX Explosion or implosion (pressure variation) FORMCHECKBOX Repetitive movement FORMCHECKBOX Muscular effort - single event FORMCHECKBOX Electricity FORMCHECKBOX Thermal (heat/cold) FORMCHECKBOX Radiation FORMCHECKBOX Chemical or substance FORMCHECKBOX Animal or insect FORMCHECKBOX Biological FORMCHECKBOX Psychological FORMCHECKBOX Vehicle FORMCHECKBOX Other: ____________________* Contributing factor/agency – select one of the following FORMCHECKBOX Machinery and fixed plant FORMCHECKBOX Mobile plant/machinery FORMCHECKBOX Vehicle (government) FORMCHECKBOX Vehicle (private) FORMCHECKBOX Powered equipment, tools and appliances FORMCHECKBOX Non-powered tools FORMCHECKBOX Non-powered equipment (e.g. playground) FORMCHECKBOX Chemicals FORMCHECKBOX Foreign objects (e.g. projectiles, splinters) FORMCHECKBOX Outdoor environment FORMCHECKBOX Indoor environment FORMCHECKBOX Animals FORMCHECKBOX Human agencies FORMCHECKBOX Biological agent FORMCHECKBOX Needle stick FORMCHECKBOX Fire/explosion FORMCHECKBOX Electricity FORMCHECKBOX Radiation/arc flash FORMCHECKBOX Stress/trauma FORMCHECKBOX Temperature FORMCHECKBOX Other : ____________________* Activity – select one of the following FORMCHECKBOX Admin general FORMCHECKBOX Chemical use FORMCHECKBOX Computer work FORMCHECKBOX Curriculum prac FORMCHECKBOX Curriculum theory FORMCHECKBOX Playground duty FORMCHECKBOX Equipment usage FORMCHECKBOX First aid FORMCHECKBOX Lifting/manual handling FORMCHECKBOX Movement around the worksite FORMCHECKBOX Grounds care FORMCHECKBOX Play (supervised/unsupervised) FORMCHECKBOX Restraining a student FORMCHECKBOX Sport FORMCHECKBOX Travel to/from workplace FORMCHECKBOX Excursions/field trip FORMCHECKBOX Work general FORMCHECKBOX Other: ___________________First Aid Details Related student first aidFor students that have been injured, there may already be a first aid record for this incident in the MyHR Student First Aid Module. During data entry, this can be linked to this record.Is there a student first aid record? FORMCHECKBOX Yes FORMCHECKBOX NoRecord number (if known): _____________________First aid informationName of person who administered first aid: _________________________________________________________________________Short description of first aid types (e.g. rest, ice, immobilisation): ____________________________________________________________________________________________________________________________________________________________________Detailed description of first aid or other medical response if necessary: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________457200-635NOTE: This is the end of the data collection form unless an additional incident type was selected e.g. electrical, security threat, motor vehicle, environmental, near miss.00NOTE: This is the end of the data collection form unless an additional incident type was selected e.g. electrical, security threat, motor vehicle, environmental, near miss.center10601THE FOLLOWING PAGES REQUIRE COMPLETION ONLY IF ONE OF THE FOLLOWING INCIDENT TYPES WAS SELECTED: electricalsecurity threatmotor vehicleenvironmentalnear plete and print only the relevant Incident Type sections.00THE FOLLOWING PAGES REQUIRE COMPLETION ONLY IF ONE OF THE FOLLOWING INCIDENT TYPES WAS SELECTED: electricalsecurity threatmotor vehicleenvironmentalnear plete and print only the relevant Incident Type sections.00ELECTRICAL DETAILS00ELECTRICAL DETAILS*Mandatory fields that must be completed.Voltage: FORMCHECKBOX High FORMCHECKBOX Low*Safety switch tripped: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not installedEquipment asset number: _________________________________________________________________________________Date of last test – safety switch: ______/______/______Date of last test and tag – equipment: ______/_______/_______ *Source of electrical event (select one of the following statements) FORMCHECKBOX Serious incident resulting in shock or injury requiring medical treatment or death. FORMCHECKBOX Shock or injury involving high voltage electrical equipment. FORMCHECKBOX Electrical work performed by an unlicensed person. FORMCHECKBOX Work performed with faulty electrical equipment. Comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________0-635SECURITY THREAT00SECURITY THREAT*Mandatory fields that must be completed.*Type of security incident: (select one or more of the following and provide details) FORMCHECKBOX Bomb threat FORMCHECKBOX Aggressive act FORMCHECKBOX Terrorism FORMCHECKBOX Verbal threat FORMCHECKBOX Biological/chemical threat FORMCHECKBOX Intruder on premises*Details of security incident: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(Note: please record at least one ‘person threatened’ or one ‘aggressor’ if applicable).Name of person/s threatenedStaff member: _____________________________________________________________________________________Student: __________________________________________________________________________________________Other person: _____________________________________________________________________________________Address and contact details of other person (if known): _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Employer of other person threatened (if known): __________________________________________________________Name of aggressor/sStaff member: _____________________________________________________________________________________Student: __________________________________________________________________________________________Other person: _____________________________________________________________________________________Address and contact details of other person (if known): _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Employer of other person threatened (if known): __________________________________________________________Immediate response (select one or more of the following) FORMCHECKBOX Contact emergency services FORMCHECKBOX Contact supervisor FORMCHECKBOX Contact counsellor (EAP) FORMCHECKBOX Contact next of kin FORMCHECKBOX Other: _______________________________________________________Resolution/outcomeReported to police FORMCHECKBOX Yes FORMCHECKBOX NoPolice report number: _______________________________________________Police contact details: _______________________________________________Further details: _____________________________________________________________________________________________________________________________________________________________________________________0-635MOTOR VEHICLE00MOTOR VEHICLE*Mandatory fields that must be completed.This form can be used to record the details of incidents involving a motor vehicle, however if incident involves more than one vehicle, a separate page should be completed for each driver.Staff driver name: __________________________________________________________________________________Student driver name: _______________________________________________________________________________(if the driver is other than a staff member or a student, fill in the details below if know). Other person driver: ________________________________________________________________________________Type of other person: FORMCHECKBOX Client FORMCHECKBOX Contractor FORMCHECKBOX Parent FORMCHECKBOX Visitor FORMCHECKBOX Volunteer FORMCHECKBOX Other: _________________________Other person’s address: ___________________________________________ State: ___________ Post code: ________Other person’s phone number: ____________________________ Other person’s employer: _______________________Select one or more to accurately describe the weather conditions at the time of incident FORMCHECKBOX Clear FORMCHECKBOX Cloudy/overcast FORMCHECKBOX Cold FORMCHECKBOX Dry FORMCHECKBOX Dusty FORMCHECKBOX Foggy FORMCHECKBOX Hot FORMCHECKBOX Humid FORMCHECKBOX Raining FORMCHECKBOX Flooding FORMCHECKBOX Sunny FORMCHECKBOX Wet FORMCHECKBOX Windy FORMCHECKBOX Icy FORMCHECKBOX SnowyTime of the day (select one): FORMCHECKBOX Dawn FORMCHECKBOX Dusk FORMCHECKBOX Daylight FORMCHECKBOX NightRoad type (select one): FORMCHECKBOX Bend FORMCHECKBOX Intersection FORMCHECKBOX Parking area FORMCHECKBOX School grounds FORMCHECKBOX StraightRoad surface conditions (select one): FORMCHECKBOX Sealed FORMCHECKBOX Unsealed – good FORMCHECKBOX Unsealed – muddy FORMCHECKBOX Unsealed – loose Vehicle details: Vehicle type: _________________________________Vehicle make: __________________________________Vehicle model: ________________________________Vehicle year: ___________________________________Registration plate number: _______________________________________________________________________*Government vehicle FORMCHECKBOX Yes FORMCHECKBOX NoDriver licence number: __________________________Number of hours worked prior to incident: _____________Number of passengers: _________________________Police report number: ____________________________left-2159FIRE00FIRE*Description of fire: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Source of fuel – select one of the following FORMCHECKBOX Flammable gas – acetylene FORMCHECKBOX Flammable gas – LPG FORMCHECKBOX Flammable gas – nitrogen FORMCHECKBOX Flammable gas – oxygen FORMCHECKBOX Flammable gas – propane FORMCHECKBOX Flammable liquid – aviation fuel FORMCHECKBOX Flammable liquid – diesel FORMCHECKBOX Flammable liquid – kerosene FORMCHECKBOX Flammable liquid – paints FORMCHECKBOX Flammable liquid – petrol FORMCHECKBOX Flammable liquid – solvents FORMCHECKBOX Flammable material FORMCHECKBOX Paper FORMCHECKBOX Plastic FORMCHECKBOX Rubber FORMCHECKBOX Vegetation FORMCHECKBOX Wood FORMCHECKBOX Other: _________________ Source of ignition – select one of the following FORMCHECKBOX Auto-ignition FORMCHECKBOX Cutting FORMCHECKBOX Electrical FORMCHECKBOX Exothermic reaction FORMCHECKBOX Friction FORMCHECKBOX Hot surface FORMCHECKBOX Lightning FORMCHECKBOX Static electricity FORMCHECKBOX Welding FORMCHECKBOX Other: _______________________ Method of extinguishment – select one of the following FORMCHECKBOX Extinguisher FORMCHECKBOX Fire blanket FORMCHECKBOX Fire hose reel FORMCHECKBOX Hydrant FORMCHECKBOX Sprinkler FORMCHECKBOX Fire brigadeWas the fire brigade called FORMCHECKBOX Yes FORMCHECKBOX No Comments: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________left34798ENVIRONMENTAL00ENVIRONMENTAL* Impact initiating event – select one of the following FORMCHECKBOX Maritime incident FORMCHECKBOX Land contamination FORMCHECKBOX Spill and release FORMCHECKBOX Theft FORMCHECKBOX Other: ________________________* Contaminant type – select one or more of the following FORMCHECKBOX Dust and particulates FORMCHECKBOX Asbestos incident FORMCHECKBOX Heat FORMCHECKBOX Light FORMCHECKBOX Noise FORMCHECKBOX Chemical FORMCHECKBOX Pesticides FORMCHECKBOX Other: ___________________Volume released (number): ______________________Unit (select either kg or litres): __________________________Volume recovered (number): ____________________Unit (select either kg or litres): __________________________Comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________left118855NEAR MISS00NEAR MISS* What contributed to the near miss? – (select one of the following) FORMCHECKBOX Machinery and fixed plant FORMCHECKBOX Mobile plant/machinery FORMCHECKBOX Vehicle {Government} FORMCHECKBOX Vehicle {private} FORMCHECKBOX Powered equipment, tools and appliances FORMCHECKBOX Non-powered hand tools FORMCHECKBOX Non-powered equipment {eg playground} FORMCHECKBOX Chemicals FORMCHECKBOX Foreign objects {eg projectiles, splinters} FORMCHECKBOX Outdoor environment FORMCHECKBOX Indoor environment FORMCHECKBOX Animals FORMCHECKBOX Human agencies FORMCHECKBOX Biological agent FORMCHECKBOX Needle stick FORMCHECKBOX Fire/Explosion FORMCHECKBOX Electricity FORMCHECKBOX Radiation/Arc Flash FORMCHECKBOX Stress/Trauma FORMCHECKBOX Temperature FORMCHECKBOX Other: specify __________________________________________________________________________________________________________________*Details of near miss (detail consequences that could have occurred): ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
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