Flash Report

• Flash Report No.:

• Site:

• Client:

• Conducted on

  Date

• Prepared by Safety Concern (Pty) Ltd

• Location
  Address

Incident Information

• Project Name:

• Project Number:

• Area of Incident:

• Date and Time of Incident:

  Date

• Date and Time Reported:

  Date

• Reported to:

• Safety Officer:

• Contractor:

• Section 16(2) / CR 6(1):

• Incident Classification:

  Select FOG Transport Machinery Electricity Fire / Explosion Fall Falling Objects Material Handling Other... explain

  • FOG
  • Transport
  • Machinery
  • Electricity
  • Fire / Explosion
  • Fall
  • Falling Objects
  • Material Handling
  • Other... explain

• Loss / Loss Potential:

  Select Fatality Injury Illness Liability Fire Damage Crime Loss Pollution Environmental Impact Damage Financial Loss Production Loss Other... explain

  • Fatality
  • Injury
  • Illness
  • Liability
  • Fire Damage
  • Crime Loss
  • Pollution
  • Environmental Impact
  • Damage
  • Financial Loss
  • Production Loss
  • Other... explain

Affected Person's Details

Particulars:

• Names and Surname:

• Contact Number:

• ID Number:

• Age:

• Gender:

  Yes

  No

  N/A

• Occupation:

• Injury Classification:

  Select FA Case Medical Treatment Case Restricted Work Case Lost Time Injury Reportable Lost Time Injury Fatality

  • FA Case
  • Medical Treatment Case
  • Restricted Work Case
  • Lost Time Injury
  • Reportable Lost Time Injury
  • Fatality

• Part of body affected:

  Select Head Hand Eye Finger Neck Leg Truck (body) Foot Back Internal Arm Multiple

  • Head
  • Hand
  • Eye
  • Finger
  • Neck
  • Leg
  • Truck (body)
  • Foot
  • Back
  • Internal
  • Arm
  • Multiple

Witness' Details

Particulars:

• Names and Surname:

• Contact Number:

• ID Number:

• Statement:

• Description of Incident:

• Photos (at least two):

  Media

• Investigator's name:

  Sign

• Responsible person's name:

  Sign