<p>SAMPLE Employer’s name and logo Slips, trips and falls investigation report Part A: Individual details Full name: Gender: Date of birth Male Female Contact phone: Address: (Work) (Home) (Mobile) Job title: Status: Fulltime Part-time Casual Contract Temp Work Area/Dep’t: Working Hours: Employed since: (date) Time in position: Details of training: when, by whom, in what, refreshers, frequency</p><p>Part B: Incident details Type: Incident Injury Time of incident (24hr): Shift start time: Illness Near miss Date of Incident: Day of week: 1st Reported to: Position: Specific location of incident:...... Describe what happened: (where, what equipment or tools were being used, who else was present– the sequence of events leading up to and after the incident)</p><p>Part C: Nature of injury/ illness Describe injury or illness: </p><p>Location of injury: (body parts affected) If near miss, how could worker have been hurt? </p><p>Treatment: Nil First aid Attended GP Taken to Hospital Admitted to Hospital Facility Name: Details: </p><p>Sample slips, trips and falls investigation report</p><p>Nature of Injury Part of Body Body Side Sprain/ strain Head Upper back Front Fracture/ dislocation Face Stomach Back Muscle/ joint disorder Neck Lower back Left Nerve damage Shoulder Groin Right Cut/ graze Upper arm Hips Dominance: Bruise Elbow Upper leg LEFT Scald/ burn Lower Arm Knees RIGHT Superficial (scratch/ chaff) Wrist Lower leg Other: Hand Ankle Fingers Foot Chest Toes Other</p><p>Mark the affected area</p><p>Part D: Mechanism of injury Description of incident: i.e., How did they fall – slip, trip or fall due to another reason (e.g., collapsed or surface gave way)</p><p>Page 2 of 5 Sample slips, trips and falls investigation report</p><p>Slips, trips and falls risk factors [select all items that could have lead to/contributed to the injury]</p><p>Risk factors Floor surface & condition check yes no n/a Floor covering – too much/ little friction Change in floor type or friction level (e.g., wet -> dry, carpet – tiles) Variation in height levels Floors in poor repair/ broken surfaces Gaps between surfaces (eg loading docks) Unstable surfaces Inclined surfaces Other:</p><p>Floor contamination check yes no n/a Oil (needs separate cleaning procedure) Water (consider drainage, water pathways) Leaves Paper Ice (eg freezer/ cool rooms) Sticky substances (eg chemicals, food products) Other:</p><p>Objects on the floor check yes no n/a Carpets & unsecured mats (poor repair) Cords & cables Boxes and other walk way obstructions Growths on floor (eg mould, weeds in pavers) Inappropriate matting (eg cardboard on floor) Process waste Other:</p><p>Ability to see floor/ walkways/ hazards check yes no n/a Inadequate walkway delineation/ markings Overall illumination/ lighting levels Sharp changes/ variation in lighting levels Safety signage not used/ available Vision obstructions (eg pushing high trolleys, walking while carrying, moving while wearing welding masks) Poorly defined nosing or treads on steps Individual’s visual abilities Other:</p><p>Cleaning/spill containment check yes no n/a Inappropriate/ inadequate clean up procedures for types of spills (including chemical selection for spills) No training of staff in cleaning procedures/ spill management No drainage or inappropriate location of drainage Inadequate or no containment for spills (esp haz substances) Signs not available/ used or used inappropriately (left out for long periods) Long/ short term exposure to chemicals causing build-up/ deterioration of surface Other:</p><p>Page 3 of 5 Sample slips, trips and falls investigation report Space & design check yes no n/a Insufficient/confined space for tasks being completed (potential obstructions in walkways) Inappropriate positioning of tasks (eg wet tasks completed in walkways) Poor design of buildings/ floor surfaces in context of tasks, environment and potential contamination Small or missing landings Other:</p><p>Stairs & stepladders check yes no n/a Stepladder and safety step design inappropriate for type of work/ work tasks Difficult steps associated with work (eg trucks) Step design issues – risings & goings height, depth, consistency, handrails, nosing/ treads Other:</p><p>Footwear & clothing check yes no n/a High/ Low friction soles Poor foot support (lateral, heel, ill fitting) Inappropriate for work tasks Clothing catches (trousers beneath shoe) Restricted clothing (hampers movement) Other: </p><p>Work activities, pace & processes check yes no n/a Changing directions when walking Potential leaks/ floor contaminants from work tasks Equipment maintenance Manual handling requirements of tasks Work pressures, workload and required pace of work Use of PPE Potential muscle fatigue Competing physical & cognitive tasks Extreme postures (compromised balance) Work systems (eg timing of work) Safety climate of organisation Time constraints and peak demands Noise/ acoustic stimuli from work processes (distraction) Other: 4 Individual factors check yes no n/a Physical limitations Influence of substances eg recreational drugs and alcohol Influence of medications Other:</p><p>Page 4 of 5 Sample slips, trips and falls investigation report</p><p>Part E – Action required [completed by OSH rep/ Supervisor/ Manager in consultation with employee, and attached to employee Incident Report] What can be done to address each of the risk factors identified</p><p>Control measures to be implemented: (use Hierarchy of Control) Corrective action required (immediate & future) By whom By when Completed Consultation 1. Employee OSH rep OSH Committee 2. Supervisor/manager Maintenance 3. Other:</p><p>4. </p><p>5. </p><p>6. </p><p>The legislation (Section 23K, Occupational Safety and Health Act 1984) requires the employer within a reasonable time after receiving the report of a hazard or injury to: (a) investigate the matter that has been reported and determine the action, if any, that the employer intends to take; and (b) notify the employee who reports the hazard or injury of the determination.</p><p>Date employee was notified Who by </p><p>Comments ...... </p><p>...... </p><p>...... </p><p>Investigation Completed by:...... (Name & Sign) ...... (Date)</p><p>...... (Position)</p><p>The legislation (Section 23I, Occupational Safety and Health Act 1984) also requires that injuries resulting in death or is of a kind that is prescribed (see Regulation 2.4 and 2.5, Occupational Safety and Health Regulations 1996) are notified to the WorkSafe Commissioner on the prescribed form (Schedule 2 - Form 1 & form 2, Occupational Safety and Health Regulations 1996). A7562821</p><p>Page 5 of 5</p>