Fm1 Incident/hazard report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date
• Location
  Address

Details of incident

• Act of violence

• Incident / near miss

• Hazard

• Property damage

• Area (floor,room,level):

• Date & time hazard/incident occurred

  Date

Details of incident/ hazard

• Describe the activity undertaken at the time?

• Describe the hazard incident as it occured

• What did you do?

• What factors do you feel caused this hazard/ incident?

• Photo of incident/location

  Media

Incident investigation

• If the incident was caused by a criminal act, have the police been notified?

  Yes

  No

  N/A

• Contact local police to report incident.

• Has a work order been logged with building management in relation to this report?

  Yes

  No

  N/A

• Work order no:

• Has the OC representative been consulted in relation to this report?

  Yes

  No

  N/A

• Notify OC representative on incident.

What were the factors that may have contributed to the incident/hazard? Consider areas below

System

• Procedures

• Workload

• Maintenance

• Task allocation

• Audits

• Other

• Please specify:

Plant & Equipment

• Size/weight

• Design

• Maintenance

• Chemicals

• Location

• Other

• Please specify:

Environment

• Access

• Housekeeping

• Lighting

• Weather/ temperature

• Floor/ground surface

• Other

• Please specify:

People

• Supervision

• Training

• Job competency

• PPE not used

• Safe work method

• Other

• Please specify:

Risk assessment

• What is the worst possible consequence of this hazard/incident occurring?
  What is the likelihood of this occurring?

• 

• Insert risk matrix from media

  Media

• Risk rating - select as appropriate

• High risk
  Immediate action required

• Significant risk
  Action required within 30 days

• Moderate risk
  Action required within 1-3 months

• Low risk
  Monitor the hazard / minimal action

Risk control

• List any short term actions that have been implemented to control the risk of repeat.

What further action needs to be taken to control the risk?

• If risk control not relevant please indicate N/A in relevant box.
  Note: when identifying appropriate controls you should start at the top of the hierarchy (try to eliminate the hazard first ).

Elimination

• Action to be taken

• By who:

• By when:

Substitution - replace item with a similar item that does the same job

• Action to be taken

• By who:

• By when:

Isolation - put a barrier between the person and hazard

• Action to be taken

• By who:

• By when:

Engineering controls - change of process, equipment, tools etc.

• Action to be taken

• By who:

• By when:

Administration controls - guidelines, swms, procedures

• Action to be taken

• By who:

• By when:

Personal Protective Equipment (PPE) - worn to provide a temporary barrier

• Action to be taken

• By who:

• By when:

Investigation completed by:

• Print name

  Sign

• Position

• Company

• Contact number