Graham Roofing Incident investigation report

• Document No.

• Date of incident

  Date

• Site

• Location of incident
  Address

• Incident details

• Prepared by

• Brief description

Investigation details

• Incident type

  Select Near miss Damage incident Fire Environmental Minor injury Major injury Exposure to harmful substances Occasional disease Dangerous occurrence Other

  • Near miss
  • Damage incident
  • Fire
  • Environmental
  • Minor injury
  • Major injury
  • Exposure to harmful substances
  • Occasional disease
  • Dangerous occurrence
  • Other

• Description

• Is someone involved (Injured)

  Yes

  No

  N/A

• Name

• Address

• Date of birth

• Job title

• Company employed by

• Was there any injury

  Yes

  No

  N/A

• Details of injury

• Treatment

• Did the injured person work after incident

  Yes

  No

  N/A

• Time lost (hours/days)

• Description of incident (include what,where,when,who and emergency measures taken)

• Weather conditions

• Was PPE worn

  Yes

  No

  N/A

• List PPE

  Select Hard hat Gloves Safety boots Overalls Goggles Safety glasses Dust mask Hi Viz clothing

  • Hard hat
  • Gloves
  • Safety boots
  • Overalls
  • Goggles
  • Safety glasses
  • Dust mask
  • Hi Viz clothing

• Is there plant or equipment involved

  Yes

  No

  N/A

• Details of plant and equipment

• Was the person competent in the use of plant

  Yes

  No

  N/A

• Is there any certification or licenses required for plant

  Yes

  No

  N/A

• See attached

  Media

Supplementary information

• Do you have RAMS,INDUCTIONS,TBT or Permits

  Yes

  No

  N/A

• RAMS

  Media

• Induction record

  Media

• Relevant TBT

  Media

• Permits if required

  Media

Witnesses

• Do you have a witness

  Yes

  No

  N/A

• Name

• Address

• Job title

• Employee

• Statement

• Signature

  Sign

Corrective and preventive actions

• Corrective action 1

  Yes

  No

  N/A

• Control measure

• To be implemented by

  Date

• Action on

• Corrective action 2

  Yes

  No

  N/A

• Control measure

• Select date

  Date

• Action on

• Corrective action 3

  Yes

  No

  N/A

• Control measure

• Select date

  Date

• Action on

• Corrective action 4

  Yes

  No

  N/A

• Control measure

• Select date

  Date

• Action on

• Corrective action 5

  Yes

  No

  N/A

• Control measure

• Select date

  Date

• Action on

• Any further required measures or information