Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Event Type
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The Event is a:
- Hazard
- Near Miss
- Personal Injury
- Environmental
- Equipment
- Non Work Related
- Occupational Exposure
- Occupational Illness/Disease
- Business Process
- External Issue
Event Details
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Brief Description:
Occurred Date/Time
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Select date
Reported Date/Time
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Select date
Location
Detailed Description
Immediate Actions Taken
Activity being Performed
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Activity being Performed:
- Admin
- Boarding/Exiting
- Equipment
- Bystander
- Catering
- Climbing
- Construction/Building
- Diving
- Dogging/Rigging
- Driving
- Electrical
- Emergency Services
- Gardening
- Housekeeping
- Human Movement
- Inspection/Observing
- Laboratory Activities
- Maintenance
- Manual Handling
- Mining
- Non Work Related Activity
- Not Specified
- Operating Equipment/Machinery
- Passenger
- Servicing
- Surveying Activities
- Towing
Objects Causing Injury
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Object Causing Injury:
- Animal
- Human Agencies
- Flora
- Drugs or Pharmaceutical
- Food and Drink
- Involved only - No Injury or Illness
- Biological Agencies
- Chemicals
- Gas
- Fire/Smoke/Heat
- Fragments
- Non Metallic Substances
- Non Physical Agency
- Radioactive Material
- Weapons
- Environment
- Equipment Non Powered
- Equipment and Tools Powered
- Hand Tools Non Powered
- Office and Household Equipment
- Machinery and Fixed Plant
- Mobile Plant
- Other Transport
- Surface Mobile Equipment
- Vehicle
Mechanism of Injury
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Mechanism of Injury:
- Biological Factors
- Bite - Other Animal
- Bite - Snake
- Bite - Sting Insect
- Effects of Heat/Cold
- Effects of Wind/Weather
- Chemical Substance
- Dismounting/Climbing Down
- Fall from Height
- Trip/Slip
- Involved Only - No Injury or Illness
- Caught between Objects
- Hit by Falling Object
- Hit by Moving Object
- Hit Object with Body Part
- Slide or Cave In
- Confinement in Oxygen Deficient Place
- Drowning or Near Drowning
- Electricity
- Mechanical Vibration
- Pressure Variations
- Radiation
- Rubbing
- Sounds - Long Term
- Sounds - Single Sudden
- Mental Stress Factors
- Muscular Stress
- Repetitive Movement
- Other Multiple Mechanisms
- Vehicle Machinery Accident
Witnesses
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Name and Contact details
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Name and Contact Details
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Name and Contact Details
Investigation Team
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Manager Name:
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Notified of Event
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To Participate in the Investigation:
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HSE Rep Name:
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Notified of Event:
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To Participate in the Investigation:
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Investigation Team Member:
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Investigation Team Member:
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Investigation Team Member:
