Fill and Sign the Texas Tdap Consent Form

Accident Report Form Developed by Easy HR Pty Ltd (ABN 67 100 061 747) http://www.easyhr.com.au Surname / Family Name ................................................................................................................... First Name ........................................................................................................................................ Day and Date of incident .................................................................................................................. Day Date Time of incident ……………………….Time Shift Commenced ...................................................... Usual employment location .............................................................................................................. Location of incident .......................................................................................................................... Site name or Unique reference number Exact Location of accident ................................................................................................................. Example - Near main entrance, Storeroom, in car park, Behind workshop, etc. What was the injury or incident ......................................................................................................... Give Full Details - eg: Cut on little finger on left hand, slip on wet floor, etc How did the incident happen? What were you doing when the incident occurred? (Describe in detail what caused the incident. Attach additional information if necessary) ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... What protective equipment was being used or worn a the time of the accident? ........................................................................................................................................................... ........................................................................................................................................................... Describe any medical treatment or follow up action required after the Incident? ........................................................................................................................................................... ........................................................................................................................................................... Was anyone else involved in the incident? If yes, please provide details. ........................................................................................................................................................... ........................................................................................................................................................... Consequence Of Incident Injury Person Affected Property Damage (Estimation only required) o Fatality o Customer o Building: $................... o Lost Time o Employee o Tools: $................... o Contractor o Plant: $................... o Other: $................... ( Not available for normal work the day after an injury) o Medical Treatment o First Aid o No Injury Easy HR Pty Ltd Version 3.12 http://www.easyhr.com.au Document Name: Accident Report Form Phone: 1300 667 331 Page 1 of 2 Witness’s names and contact number (attach witness statements if available) Name Contact Details To whom was the accident reported? ............................................................................................... When was the accident reported? ..................................................................................................... In your opinion, what action if any, could be taken to prevent a recurrence of the incident ? ........................................................................................................................................................... ........................................................................................................................................................... Was an ambulance called ? o No o Yes→ Incident No: .................................... Where the police called ? o No o Yes→ Incident No: .................................... Was Trauma Counselling Offered ? o No o Yes→ Date Contacted: ............................. Was Medical treatment Sought ? o No o Yes→ Location: ........................................ Date & Time ................................. .......................................... Employee Name ............................................... Signature .................. Date SUPERVISORS USE ONLY To whom was the accident reported? .............................................................................................. Date and time accident reported? .................................................................................................... Supervisors Comments & Initial Investigation Notes: ...................................................................... ........................................................................................................................................................... Supervisors Follow Up Action Required: .......................................................................................... ........................................................................................................................................................... Target date for follow up action: ....................................................................................................... Follow up action to be performed by whom?: ................................................................................... o Yes Will the injured employee be off work for more than 7 calendar days? Have all possible actions been taken to prevent a re-occurrence? ....................................................................... Supervisors Signature & Name o Yes o No o No ................................. Date Signed Important Notes: Requirements for reporting incidents vary between states. You should be aware that you may be required to report this incident to your Workers Compensation insurer within 48 hours. In addition you may be required to report this incident to the Workcover Authority. You must keep this incident report for the period of time specified by the Workcover authority in your state. Please visit the Easy HR website for links to the Workcover Authority in your state. Easy HR Pty Ltd Version 3.12 http://www.easyhr.com.au Document Name: Accident Report Form Phone: 1300 667 331 Page 2 of 2