Event Notification Form

• Site conducted

  Select

• Notification Number

• myEHS Event ID

• Event Type

  Incident

  Near Miss or Hazard

  Inspection

  General Complaint/Inquiry

• Date

  Date

• Prepared By

• Location
  Address

• Please use attached matrix's to calculate the health and safety and Environmental risk scores.

  

• 

A. About the Event - to be completed by the person involved

• Event Type

• Incident

  Yes

• AOD Checklist to be completed

  Yes

• Near Miss hazard

  Yes

• AOD Checklist to be completed

  Yes

• Inspection

  Yes

• General Inquiry / Compliant

  Yes

• Event Date & Time

  Date

• Department

• Specific Area/Location (e.g. line, rego)

• Event Classification

  Health & Safety

  Environment

  EHS

• Did this happen at a non-PepsiCo workplace (e.g. supermarket)?

  YES

  NO

• Note: If yes You MUST inform the client immediately.

• Describe what happened/what could have happened/hazard details (include exact location, details of task being undertaken, plant, equipment, substance involved). Attach additional information/form as required.

• Were there any witnesses?

  YES

  NO
Witness

• Name

• Contact Number

• Location

• What have you done to remove or reduce the immediate risk?

• Work Request Number

B. About the Person Reporting - to be completed by the person involved

• Person involved

  Employee

  Temp/Agency

  3rd Party (visitor/public)

  Contractor

• Company Name

• Function

  Select Ops-Manufacturing Ops-S&D Transport Agro Sales R&D Other (e.g. Admin/HR/IT/Accounts)

  • Ops-Manufacturing
  • Ops-S&D
  • Transport
  • Agro
  • Sales
  • R&D
  • Other (e.g. Admin/HR/IT/Accounts)

• Specify

• Family Name

• Given Name(s)

• Occupation

• Person Reporting (If different to person involved)

• Who have you notified about this event? (You MUST notify a PepsiCo Supervisor within 2 hours & by the end of your shift)

• What date & time did you notify them?

  Date

• Involved Person Signature

  Sign

• Supervisor Signature

  Sign

C. Impact of the Event - to be completed by the person Supervisor

• Event Impact

  Select Real (actual loss/injury) Potential (for near miss/hazards)

  • Real (actual loss/injury)
  • Potential (for near miss/hazards)

• Nature of Impact

  Human

  Environment

  Property Damage

  Vehicle

  Media/PR

• HUMAN NATURE IMPACT:

• Work related?

  YES

  NO

• Level of Treatment

  No Injury

  Minor Injury

  First Aid

  Medical Treatment

  Lost Time

• Part of the Body (specify left or right part)

• Type of Injury (e.g. cut/sprain/bruise etc)

• Injury treatment conducted?

  YES

  NO

• First Aider Name & Sign (if applicable)

  Sign

• First Aider Date (if applicable)

  Date

• Treatment Given

• Injured person returned to work?

  YES

  NO

• Date & time the injured person returned to work

  Date

• ENVIRONMENT NATURE IMPACT:

• Medium Impacted

  Select Air Water Waste Ground Chemical Other

  • Air
  • Water
  • Waste
  • Ground
  • Chemical
  • Other

• Specify

• Location

  On-Site

  Off-Site

  On-Site & Off-Site

• Reportable Quantities Exceeded?

  Yes

  No

  Unknown

  N/A

• DURATION OF THE EVENT:

• Date & Time Started

  Date

• Date & Time Stopped

  Date

• Type, Volume and Concentration of any substances released (if applicable)

• Sample Taken?

  YES

  NO

• Spill response equipment used/deployed (if applicable)

• Category of Impact (select the most severe impact level)

  Select Undetermined Near Miss Level 0 Level 1 (immediate escalation required) Level 2 (immediate escalation required)

  • Undetermined
  • Near Miss
  • Level 0
  • Level 1 (immediate escalation required)
  • Level 2 (immediate escalation required)

Human Impact

• Work Related

  YES

  NO

• Level of Treatment

  No Injury

  Minor Injury

  First Aid

  Medical Treatment

  Lost Time

• Part of Body

• Left/ Right

• Type of Injury. e.g cut/sprain/bruise etc.

Injury Treatment

• First Aider name if Applicable

• First Aider Signature if Applicable

  Sign

• First Aider Date (If Applicable)

  Date

• Treatment given if applicable

• Date injured person returned to work.

• Time injured person returned to work

• Not yet returned to work

Environmental

• Medium Impacted

  Select Air Water Waste ground Chemical Other ( please specify)

  • Air
  • Water
  • Waste
  • ground
  • Chemical
  • Other ( please specify)

• Location

  On Site

  Off Site

  On and Off Site

• Reportable Quantities Exceeded?

  Yes

  No

  Unknown

  N/A

• Duration of Event: Date and Time Started

  Date

• Date and Time Stopped

  Date

• Type , Volume and concentration of any substances released ( If Applicable)

• Sample Taken

  YES

  NO

• Spill response Equipment used/deployed if applicable.

D. Potential Severity - What could have happened - to be completed by the Supervisor

• Completed in Consultation With : (Name & Signature)

  Sign

• Date

  Date

• Consequence

• Likelihood

• Outcome

• Extreme - HIPO (If yes follow correct Escalation Procedure FULL Investigation required)

  YES

  NO

• High - HIPO (If yes follow correct Escalation Procedure FULL Investigation required)

  YES

  NO

• Moderate Outcome

  YES

  NO

• Low Outcome

  YES

  NO

E. Immediate Causes of the Event - to be completed by the investigation team

• Completed in Consultation With (minimum required: HSR & Management representative for Near Miss. Refer to investigation procedure for further details)

• Immediate cause of the incident

  Substandard Actions

  Substandard Conditions

• Details

• Completion of the investigation including root causes must occur within 14 days & be loaded to myEHS

F. Immediate Corrective Action Taken

• Immediate Corrective Actions to Prevent Further Loss

Action

• Description of Action Taken

• By Who

• Date of Completion

  Date

• my EHS Action Plan ID Number

G. About the Supervisor Completing this Form

• Family Name & Given Name(s)

• Contact Number

• Occupation

• Sign

  Sign

• Date

  Date

H. Circulation

• Employee (feedback received) : (Name & Signature)

  Sign

• Date

  Date

• EHS Management Team : (Name & Signature)

  Sign

• Date

  Date

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PANZ-FOR-028 AOD REASONABLE SUSPICION ASSESSMENT CHECKLIST

• Checklist instructions: Where workers are involved in an incident /near miss the Supervisor or Manager must complete the AOD reasonable suspicion checklist as part of the incident reporting process to determine if a worker’s fitness for work may have been a contributing factor in the cause of the incident. If fitness for work factors are identified below refer to PANZ-POL- 004 Alcohol and Other Drugs Policy for further instruction. Where possible and reasonable, observations should be confirmed by another supervisor and/or manager prior to initiating testing.

EMPLOYEES DETAILS

• Name:

• Position:

• Department:

• Shift:

• Managers name:

• Position:

OBSERVATIONS:

• Supervisor/manager to list observations that are out of character and that lead to safety performance concerns.

SPEECH

• Slurred

  Yes

• Thick

  Yes

• Incoherent

  Yes

• Shouting

  Yes

• Rambling

  Yes

EYES

• Bloodshot

  Yes

• Glassy

  Yes

• Watery

  Yes

• Dilated

  Yes

• Droopy

  Yes

APPEARANCE

• Grinding of teeth

  Yes

• Having odour

  Yes

• Unusually dishevelled

  Yes

• Flushed

  Yes

• Pale

  Yes

• Sweaty

  Yes

EXPRESSION

• Blank

  Yes

• Unresponsive

  Yes

• Panicked

  Yes

• Confused

  Yes

BEHAVIOUR

• Agitated

  Yes

• Argumentative/Threating

  Yes

• Drowsy

  Yes

• Stupor-like

  Yes

• Hyperactive

  Yes

• Unusually Talkative

  Yes

• Erratic

  Yes

• Dazed

  Yes

• Uncommunicative

  Yes

• Uncooperative

  Yes

• Defiant

  Yes

• Emotional/crying

  Yes

• Unusually calm

  Yes

• Nervous

  Yes

MOVEMENTS

• Unsteady/Swaying/Staggering

  Yes

• Fumbling/Jerky/Uncoordinated

  Yes

• Excessively Slow /Delibrate

  Yes

• Excessively Fast / Reckless

  Yes

• Shaking/Tremulous

  Yes

• Sagging/Leaning

  Yes

MISCELLANEOUS

• Presence of alcohol, suspected drugs and/or paraphernalia in possession or in vacinity

  Yes

• Admission of possession /usage of alcohol and/or drugs

  Yes

• Difficulty in recalling instructions

  Yes

• On-the-job misconduct

  Yes

• Suspicious and unusual behaviour (please detail below)

  Yes

• Changes in work pattersns/performance

  Yes

OTHER OBSERVATIONS/FURTHER DETAILS (Supervisor/Manager to specify)

• WHERE AOD TESTING HAS BEEN DEEMED NECESSARY PLEASE CONTACT : INTEGRITY SAMPLING ON PHONE 1800 633 838.

OBSERVATION VERIFICATION (To be completed by the observing supervisor/manager)

• Date:

• Time:

• Signature

  Sign

CONFIRMATION OF OBSERVATIONS ( To be completed by another supervisor prior to testing)

• Date:

• Time:

• Signature:

  Sign

COMPLETION OF EVENT NOTIFICATION FORM. (When all information above has been completed please select yes to submit form)

• When ALL sections have been completed, please select yes to submit.

  Yes