<p>THE BAROSSA COUNCIL</p><p>INCIDENT REPORT FORM</p><p>Area: Work Health and Safety Document Number: TBCFOR3302 Form Owner: CEO Executive Services Last Revised Date: 27 February 2014 Document Control: Risk Management Team Entry TRIM Reference: B2200 / Date Approved: 5 September 2012 Next Review Date: 5 September 2015</p><p>1. Incident Title and Identification Number (Generated from SharePoint entry) SharePoint Pathways ID Title (Example: Contractor sustained broken arm in fall from height) ID No No</p><p>2. Incident Type (Excluding Hazard Reports) Personal Injury Near Miss Actual Personal Injury – Report Environmental Impact Only Business Pre-existing Medical WHS Incident Type Process/Behaviour Condition Occupational Non-Work Related Illness/Disease Property/Equipment Other Damage Volunteer (including S41, Community (General) Transport, Home Assist) Government/Regulatory Council Workgroup Workers Compensation Group Type Mutual Liability Scheme Scheme Motor Vehicle Schedule Asset Schedule Potential Level 1 (Low) Level 2 (Medium) Level 3 (High) (Refer to TBCPR3304 - Incident Reporting & Investigation Process)</p><p>3. Involved Person (If more than one person involved fill in details. All persons involved, whether injured or not, should be listed.)</p><p>Status Employee Volunteer Contractor Member of Public Name(s)/Guardian(s) Contact Details</p><p>4. Report Details</p><p>Time of Date Time Date Incident Occurred // // Incident Reported Reported </p><p>Witness Name Address Contact Number</p><p>Brief Description (Short summary of what has happened (including vehicle/plant make/model & registration no if applicable) </p><p>Immediate Action Taken (To make situation or area safe if required – leave blank if not applicable.) Please attach extra sheet if needed.</p><p>Is further investigation required? Yes No Preventative or Correction Action(s) Required? Yes No If Yes, CAPA Register item required Does the Hazard Register need to be updated Yes No</p><p>Where did the incident occur? Provide Specific Location (e.g. Road Name) </p><p>The Barossa Council © 2014 Form: Incident Report Form TRIM TEMPLATE REF: 13/21038 Page 1 of 3 The electronic version of this document is the controlled version. Printed copies are considered uncontrolled. Printed Copies are uncontrolled for 3 months from 4/05/2018 and then must be reprinted Visitor Information Centre Depot Private Residence Library</p><p>Barossa Regional Gallery Roadway/Footpaths Refuse Tip Reserve/Park/Oval Council Office In Transit Swimming Pool Recreation Centre</p><p>Other </p><p>Hazard Type</p><p>Slip/Trip/Fall Falling Object Caught In Struck by Manual Handling Environmental conditions Harmful Contact/Exposure Recurrence</p><p>Stress/Anxiety Safe Act Observation A B C Other </p><p>Injury Type</p><p>Property/Environmental Fracture Internal Injury Burns Psychological Damage </p><p>Dislocation Open Wound Poisoning Exposure</p><p>Aggravation of previous Sprain/Strain Superficial Injury Multiple Injuries condition</p><p>Head Injury Eye Injury Rash/Dermatitis Other </p><p>Bruising Bite/Sting Currently Unknown NA</p><p>Affected Area Head Trunk System Arm Hand Leg Foot Property</p><p>Eye Neck Heart Left Left Left Left Council</p><p>Ear Hip Lungs Right Right Right Right Public</p><p>Nose Chest Circulatory Shoulder Thumb Knee Toe Environmental</p><p>Mouth Stomach Respiratory Upper Arm Fingers Lower Leg Foot Vehicle/Plant</p><p>Skull Upper back Nervous Forearm Hand Upper Leg Heel Other</p><p>Face Lower back Psychological Wrist Other Ankle</p><p>Ribs Digestive Elbow</p><p>Treatment Associated Services Outcome Associated Issues</p><p>No Treatment Police Nil - Report Only Motor Vehicle First Aid (on site) Claims Remainder of day (medical) Injury to other person(s)</p><p>Medical treatment Ambulance Unfit for work (LTI) Damage to property Doctor (Outpatient) Fire Unfit for a number of days (LTI) Environmental damage</p><p>Admitted to hospital SafeWork SA Modified duties Bullying/Harassment</p><p>Date and time if work ceased Name of First Aid Officer:</p><p>// @ am/pm</p><p>Notification Health & Safety Regional Risk Relevant Supervisor Risk Management Team Representative (HSR) Coordinator (RRC)</p><p>5. Notifiable Incident (Refer TBCPR3304 - Incident Reporting and Investigation Process)</p><p>Has this risk event resulted in a Notifiable Incident? Yes No</p><p>If Yes – the incident must be reported to SafeWork SA by the person in charge of the workplace (or delegate)</p><p>Date Reported // Reported By (print name)</p><p>6. Sign Offs</p><p>//</p><p>The Barossa Council © 2014 Form: Incident Report Form TRIM TEMPLATE REF: 13/21038 Page 2 of 3 The electronic version of this document is the controlled version. Printed copies are considered uncontrolled. Printed Copies are uncontrolled for 3 months from 4/05/2018 and then must be reprinted Name of Supervisor/Manager Signature Date</p><p>// Name of Person Involved in Incident Signature Date</p><p>The Barossa Council © 2014 Form: Incident Report Form TRIM TEMPLATE REF: 13/21038 Page 3 of 3 The electronic version of this document is the controlled version. Printed copies are considered uncontrolled. Printed Copies are uncontrolled for 3 months from 4/05/2018 and then must be reprinted</p>