Back Manager Follow Up - World Gym BurpengaryToday's Date* DD slash MM slash YYYY Related Forms Entries (ID)Name Of Incident*Incident | Accident Date*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time of Incident : Hours Minutes AM PM AM/PM MANAGEMENT REVIEWHas the incident been investigated:* Yes No If no, please explain whyOutcome of investigation:*Please use this section to describe the investigation and outcomesManager's Name*SignatureOriginal form retained at Workplace* Yes No Please explain why:Post Incident | Staff DebriefPlease list full names of affected Staff/ContractorsFollow up* Yes No Has Manager met with affected staff/contractor to discuss incident:Comments on Follow UpIs further counselling required?* Yes No Where were the affected staff members/contractors referred to:WHS EvaluationPlease indicate the likelihood of re-occurrence* Low Risk Moderate Risk High Risk Action taken to mitigate further risk
