ASCIANO IT - Incident Notification Form Checklist

Name of Person Completing the Report

Location of Incident

Work Activity being undertaken at time of Incident

Surname

First name

Address

DOB

Phone Number

Employee ID number

Shift Start Time

Year Employed in Role

Occupation

Surname

First Name

Address

Contact Telephone

Account of how incident occurred (including witnesses, brief summary leading up to incident). Includes facts about the sequence of events and the conditions existing at the time i.e. lighting, surface, property damage etc.

What immediate actions were taken?

Part of Body Injured

Nature of Injury

First Aid Attendants name

Other (describe)

Other (describe)

Describe damage to property - specify Asciano property or other property

Interim actions taken to prevent reoccurrence.

Cost of Damage