Information

  • Document No.

  • Incident report

  • Barrick

  • Conducted on

  • Prepared by Jason Lister

  • Location
  • Personnel B crew

Part A

  • Hazard

  • Near Miss (part A mandatory)

  • Injury or Illness (Part A & C mandatory)

  • High Potential (to be reported to regional VP and EHS manager within 24hrs)

  • Environment (Part A & B mandatory)

  • Community Contact (Part A & B mandatory)

  • Production Loss (Part A mandatory)

  • Property Damage (Part A mandatory)

  • Estimated cost or loss or damage $

  • Other (Specify) part A mandatory

  • Theft (Part A mandatory)

  • Estimated cost of theft $

  • Date & time of event

  • Date & time of report

Reported by

  • Add signature

Location

Work area

Person involved

  • Name -

  • Employee number -

  • Gender -

  • Department

  • Occupation

  • Full time

  • Part time

  • Casual

  • Direct employee

  • Contractor

  • Other (Please specify)

  • Company name -

  • Specify -

Shift details

  • Day

  • Night

  • Shift length

  • 10hrs

  • 12hrs

  • Other (specify)

  • Specify

  • Roster type (ie. 2 weeks on / 1 week off)

  • Days into roster (ie. day 3)

  • Shift start time

Equipment or property involved

Witness (attach statements as required)

  • Add signature

  • Add signature

  • Add signature

  • Add signature

Brief description (Attach sketch if required)

  • Add drawing

  • Event photo

Risk assessment

  • Consequence

  • Likelihood

  • Risk Rating

  • Further investigation required

  • Incident report form

  • Taproot

Immediate actions taken

Part B: Environmental Details

  • Spillage or release

  • Type

  • Volume

  • From

  • To

  • Area

  • Wildlife mortality

  • Noise

  • Vegetation damage

  • Dust

  • Community / Archeological

  • Vibration

  • Regulator

  • Other (Specify)

Further details and comments

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