Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location of event

  • Your department

  • Which Maint group

  • Which group

  • Which group

  • Which group

  • Which group

  • Which group

  • Was equipment involved

  • Equipment type and numbers

  • How many days into rotation

  • Shift

  • What part of shift did the Incident occur in

  • Which Critical Risk would this be classified under?

  • Select the PTW program

  • Select type of energy

Critical Risk- incident

  • Please select classification

  • Event Type

  • Complete description

  • Photo(s) of incident

  • Immediate action(s) taken

  • Reported to who

  • What controls

  • What controls were added

  • Potential actions (long term)

  • Notify Committee

  • Incident Loss

  • Body part effected

  • FAST team member

  • Incident Type

  • Photo(s) of incident

  • Complete description

  • Immediate action(s) taken

  • Reported to who

  • What controls

  • Comment required

  • Potential actions (long term)

  • Incident Loss

  • Body part effected

  • Incident Type

  • Photo(s) of incident

  • Complete description

  • Immediate action(s) taken

  • Reported to who

  • What controls

  • What controls were added

  • Potential actions (long term)

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