Incident & Injury Investigation Report Incident & Injury Investigation Report WORKER DETAILS Worker Photo Drop a file here or click to upload Choose File Maximum file size: 52.43MB Employee Name * Employee Name First First Last Last Phone * Date of Birth Age Range 15 - 19 years20 - 25 years26 - 30 yearsOver 30 years Trade * PlumberRoof PlumberElectricalRooferSheetmetalRefrigerationClerk Year * 1st Yr2nd Yr3rd Yr4th YrLevel 1Level 2Level 3Level 4 Host Employer Field Officer OtherJoe ScopacasaMario CappellaRicky ThomasShaun HillBrayden Wild Field Officer INCIDENT DETAILS Incident Date * Incident Time * 000102030405060708091011121314151617181920212223 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 Incident Reported By: ApprenticeHost EmployerWork ColleagueNot Reported to TAPSNot known / unclear To whom in TAPS was the Incident reported? Incident Reported to TAPS Date Incident Reported to TAPS Time 000102030405060708091011121314151617181920212223 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 Has your Host been notified? Yes No Incident Investigated Date SPECIFICS OF INCIDENT Location of the Incident Nature of the work the worker was involved in at the time of the incident Outline specifically what happened / how this happened Injury or Illness? Injury Illness Injury (01) Fractures (excluding vertebral column)(02) Fractures of vertebral column (with or without mention of spinal cord lesion)(03) Dislocations(04) Strain or sprain of joints and adjacent muscles(05) Intracranial injury including concussion(06) Internal injury of chest abdomen and pelvis(07) Traumatic amputation including enucleation of eye(08) Open wound not involving traumatic amputation (laceration, puncture, wound)(09) Superficial injury(10) Contusion with intact skin and crushing injury (contusion/bruise/abrasion)(11) Foreign body on eye, in ear, nose, respiratory, digestive system(12) Burns(13) Nerve and spinal cord injury(14) Poisoning and toxic effects of substances(15) Effects of weather / air pressure(16) Multiple injuries(17) Damage to artificial aids(19) Other / unspecified injuries Illness (21) Deafness(22) Eye disorders (non traumatic)(28) Diseases of nervous system and sense organs(31) Diseases of muscles, tendons, soft tissue(38) Diseases of musculoskeletal system(41) Dermatitis and eczema(51) Hernia(58) Diseases of digestive system(61) Infectious and parasitic diseases(71) Diseases of respiratory system(81) Circulatory system(91) Cancers and other neoplasms(95) Mental disorders(98) Other diseases Specifics (if needed) Injury Photo Drop a file here or click to upload Choose File Maximum file size: 52.43MB Have you ever had the same or similar injury before? Yes No When did this occur and was this connected to work? Body Location - General (01) Eye(02) Ear(03) Face(04) Head (other than eye/ear/face)(05) Neck(06) Back(07) Trunk (other than back or internal)(08) Shoulders and arms(09) Hands / Fingers(10) Hips and legs(11) Feet and toes(12) Internal Organs(98) Multiple locations(99) General and unspecified locations Body Location - Description Mechanism (per AS 1885.1) (01) Fall from a height(02) Falls on the same level (including trips and slips)(03) Hitting objects with a part of the body(04) Exposure to mechanical Vibration(05) Being hit by moving or falling objects(06) Exposure to sharp sudden sound(07) Long term exposure to sounds(08) Exposure to variations in pressure (other than sound)(09) Repetitive Movement with low muscle loading(10) Other muscular stress(11) Contact with electricity(12) Contact / exposure to heat or cold(13) Exposure to radiation(14) Single contact with chemical or substance(15) Long term contact with chemicals or substances (i.e. dust, dirt etc)(16) Other contact including insect and spider bites and stings(17) Contact with / exposure to biological factors(18) Exposure to mental stress factors(19) Slide of cave-in(20) Vehicle Accident(98) Other and multiple mechanisms of injury(99) Unspecified mechanisms of injury Agency (per AS 1885.1) (01) Machinery and fixed plant(02) Mobile Plant(03) Road Transport(04) Other transport(05) Powered equipment, tools and appliances(06) Non powered hand tools(07) Non powered equipment(08) Chemicals(09) Non metallic substances(10) Other materials, substances or objects(11) Outdoor environment(12) Indoor environment(13) Underground environment(14) Live animals(15) Non living animals(16) Human agencies(17) Biological agencies(18) Non physical agencies(98) Other agencies(99) Unspecified agencies If you are human, leave this field blank. Next
