Information
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Civil Contract audit been carried out on
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Company Name
- Heneghans
- Perfecta
- Northfield
- McLoughlin
- LDH
- Heneghan Comms
- AGM
- C&A
- F-Tech
- CWB
- Comm Installation
- McHugh Comms
- Fibre Tech Solutions
- Cusack
- Other
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Date and time Accident / Incident was reported.
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Location of Accident / Incident
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Reported By
- Gareth Lindsay
- A1 Trafficmanagement
- Kirk Ogilsby
- Kris Ogilsby
- Craig Scutt
- Joe Duggan
- Kevin Murphy
- Jamie Ayrton
- Des Rogan
- John Walsh
- John Whitehead
- Sean Delaney
- Chris Gunn
- Phil Edgell
- Gary Handley
- Bob Morris
- Mick Elhinney
- Rob Austin
- Matt Eagling
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Build Area
Accident / Incident Details
PERSON(S) INVOLOVED
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Name (Person 1):
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Sex:
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D.O.B
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Address Details
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Phone number
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Do you require to complete a 2nd person injury
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Name of Person 2
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Sex:
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D.O.B
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Address Details
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Phone number
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Type of Accident
- Vehicle
- Plant
- Personal Injury
- Other
- Property
- N/A
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Name of other person involved
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Third Party Contact Details
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Third Party Address Details
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Third party Insurance Details if at Hand
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Photographes of damage.
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Vehicle Reg:
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Make/Model:
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Age:
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Enviroment
- DAY LIGHT
- NIGHT TIME
- DAWN
- LOW SUN
- HIGH SUN
- OVERCAST
- FOG
- ICY
- SNOW
- WINDY
- RAINING
- INDOOR
- OUTDOOR
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Ground Conditions
- UNEVEN
- FLAT
- SLOPING
- Icey
- WET
- DRY
- SURFACE PROBLEMS
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Equipment / Processes
- DRIVING
- USING HAND TOOLS
- OPERATING MACHINERY
- DRILLING
- USING WAH EQUIPMENT
- MANUAL HANDLING EQUIPMENT
- PULLING CABLE
- LIFTING PIT COVERS
- ELETRICAL
- SUBSTANCES
- AIR TOOLS
- WARNING DEVICES
- HOT WORKS
- PROPERTY
- N/A
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Was there any witness(es)? If yes, provide name(s).
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Please supply a name and contact number.
NATURE OF Accident / Incident
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Type Of Accident / Incident
- MOTOR ACCIDENT / INCIDENT
- PHYSICALLY ASSAULTED BY PERSON
- INJURED BY ANIMAL
- COLLAPSING/OVERTURNING OF STRUCTURE
- COLLAPSING/OVERTURNING OF STRUCTURE (RIDDOR)
- CONTACT WITH FIRE / HOT SURFACE
- CONTACT WITH MOVING MACHINERY
- CONTACT WITH SHARP OBJECT
- MOTOR VEHICAL COLLISION
- SLIP, TRIP OR FALLS ON SAME LEVEL
- FALLS / SLIPS EXITING VEHICLE
- FALLS FROM HEIGHT 0-1 METER
- FALLS FROM 1-2 METER
- FALLS FROM HEIGHT >2 METER
- STRUCK BY MOVING, INCLUDING FLYING / FALLING OBJECTS
- STRUCK BY MOVING VEHICLE
- INJURED WHILST REACHING
- INJURED WHILE HANDLING, LIFTING OR CARRYING
- EXPOSURE TO FIRE OR STEAM
- EXPOSURE TO AN EXPLOSION
- EXPOSURE TO, OR CONTACT WITH A HARMFUL SUBSTANCE
- EXPOSURE TO, OR CONTACT WITH A PHYSICAL HAZARD
- STRUCK AGAINST FIXED OR STATIONARY OBJECT
- THEFT OF EQUIMENT
- DAMAGE TO EQUIPMENT
- SPILLAGE OF SUBSTANCE
- SAFETY OBSERVATION
- PROPERTY
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Describe the advents leading up to the accident / Incident taking place.
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Detail any first-aid or medical treatment administered.
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Photographs of Accident / Incident scene .
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Detailed description of Accident / incident.
Qualification and on site Risk Assessment Evidence
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Please take Photo of Risk ass and any qualification if applicable.
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TIME AND DATE COMPLETED
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Signature
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PLEASE CONFIRM YES ONCE COMPLETED
