Cowal Gold Mine Incident Report

• Document No.

• Incident report

• Barrick

• Conducted on

  Date

• Prepared by Jason Lister

• Location
  Address

• 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

• Date & time of report

  Date

Reported by

• Add signature

  Sign

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

  Date

Equipment or property involved

Witness (attach statements as required)

• Add signature

  Sign

• Add signature

  Sign

• Add signature

  Sign

• Add signature

  Sign

Brief description (Attach sketch if required)

• Add drawing

  Drawing

• Event photo

  Media

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