Information
-
Client / Site
-
Prepared by
-
Conducted on
-
Document No.
Section 1
THIS DOCUMENT IS SPLIT INTO 2 SECTIONS. TOOGLE THROUGH THE SECTIONS AT THE BOTTOM OF THE PAGE.
SECTION 1 - Accident/Incident Type
-
Select either 'Personal', Event' or 'Near Hit'
-
PERSONAL (non work related injury)
-
EVENT - Accident/incident resulting in injury, illness, damage or harm.
-
DAMAGE TO PLANT OR EQUIPMENT
-
Select Type
-
ENVIRONMENTAL
-
Select Type
-
Please specify
-
NEAR HIT - An incident that had the potential in resulting in injury, illness, damage or harm.
NOTE: For 'Near Hit' complete investigation in relation to potential outcome of incident.
Initial Report Status
-
First Aid
Revised Status (if revised)
-
Medically Treated Injury
-
Lost Time Injury
Once complete email copies of this to Senior Management and Safety Department.
Section 2
THIS DOCUMENT IS SPLIT INTO 2 SECTIONS. TOOGLE THROUGH THE SECTIONS AT THE BOTTOM OF THE PAGE.
SECTION 2 - Incident Details
-
Date and Time of Accident/Incident
-
Date and Time of Investigation Report
-
Person(s) Carrying Out Investigation
-
Contractor
-
Contract Persons' Drivers Licence
-
Location of Accident/Incident
-
Activity at Time of Accident/Incident
Person(s) Involved
-
Full Name of Employee(s)
Employee
-
Full Name
-
Supervisor
-
Safety Advisor/Representative
-
Any Witnesses
Witness
-
Witness Name
What Happened/What Was Observed
-
Please only state factual information.
Examples: What is the damage or loss - What was the injured party doing - What had the injured party been instructed to do - What tools were being used - What did the injured/witness see - What safety rules were violated - What safety procedures were in place - What permits were being used - What isolation procedures were in place - What training had been given - What communication system was in place at the time -
Employee Statement Form
Statement
-
Statement
-
Name and Signature
-
Witness
