Title Page
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Site
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Date of Report
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Location
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Date and Time of incident
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Witnesses
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Report By
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Supervisor
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1. Please provide responses on the questions below.
2. Take a photo by clicking on the "Add Media Button"
3. To add a Corrective Measure click on the paperclip icon then "Add Action", provide a description, assign to a member, set priority, and due date
4. Complete audit by providing digital signature
5. Share your report by exporting as PDF, Word, Excel or Web Link. -
Equipment Damage / Loss/ Theft
Aurum employees are required to report any damage, loss or theft of Aurum owned and operated equipment as soon as possible and submit a completed copy of this form to your supervisor.
Completed report forms must be submitted to your Project Manager or Health & Safety Coordinator on the same day as incident occurred, by 6pm.
Please note that where an injury occurs as a result of any damage, loss or theft of Aurum owned and operated equipment, employees are required to report the incident immediately, and submit a completed Accident Report Form.
Details of Incident
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Type of Damage
- • Equipment Damage
- • Loss
- • Theft
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Nature of Incident
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Work Carried Out
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Name(S) of Person Involved
• PERSON
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Please specify Name
Equipment Information
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List of Equipment Damaged / Lost / Stolen
• ITEM
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Please specify item
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Upload an image
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Equipment Identification Number(s)
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Upload an image
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Equipment Location at Time of Damage / Loss
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Upload an image
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How Was the Equipment Damaged / Lost / Stolen? (Complete Description)
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Description of Damage to Equipment
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Upload an image
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Estimated Cost of Repair / Replacement
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Person Responsible for Equipment
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Was the equipment damage/loss/theft reported to the police?
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Police File No.
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Station No.
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Officer in charge
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A Police Report (if Theft) and replacement cost invoice must be attached
General Comments and Observations
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Please add additional comments and observations
Completion
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Reporting Employee Name and Signature
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Supervisor Name and Signature
