Immediate Notification Form

• Client / Site

• Location
  Address

• Conducted on

  Date

• Prepared by

• Audit Title

• Immediate notification form

• DA-ZH-FM006.3

IMMEDIATE NOTIFICATION

• Date & Time of Incident:

  Date
• At what location / Site did the incident occur?
  Address

• INX number:

• List any thrid party affected:

• What exactly happened? (Facts Only)

INJURY DETAILS (if applicable)

• Name of Injured Person:

• What injuries did the person suffer?

• Will hospitalisation is requried? (Imaging, Splinting, Surgery...)

• Is "Ttime Lost" by the injured person expected?

  Yes

  No

  N/A

• Has the injured worker received a First Medical Certificate from a medical practitioner stating "Unfit for Work"?

  Yes

  No

  N/A

• Was ther person escorted by a Downer representative during the consult with the medical practitioner?

  Yes

  No

  N/A

• Was the worker provided with possible alternative duties during the consult with the doctor?

  Yes

  No

  N/A

PLANT & EQUIPMENT

• If plant / Equipment / Property were damaged, discribe the damage:

ASSESS THE RISK

• Where actual conequence of event is low, but probability of a serious event is high, the describe what a reasonably foreseeable outcome may be for this incident?

• Consequence

  1 Low

  2 Minor

  3 Moderate

  4 Major

  5 Catastrophic

• Likelyhood

  A Almost Certain

  B Likely

  C Possible

  D Unlikely

  E Rare

• Risk Rating

  Low

  Medium

  High

  Extreme

CONTROL THE RISK

• Immediate corrective actions taken:

  Yes

  No

  N/A

• Select Elimination Substitution Isolation Engineering Administration PPE

  • Elimination
  • Substitution
  • Isolation
  • Engineering
  • Administration
  • PPE

• Action taken / Lessons Learned

• Additional corrective actions taken:

  Yes

  No

  N/A

• Select Elimination Substitution Isolation Engineering Administration PPE

  • Elimination
  • Substitution
  • Isolation
  • Engineering
  • Administration
  • PPE

• Action taken / Lessons Learned

• Additional corrective actions taken:

  Yes

  No

  N/A

• Select Elimination Substitution Isolation Engineering Administration PPE

  • Elimination
  • Substitution
  • Isolation
  • Engineering
  • Administration
  • PPE

• Action taken / Lessons Learned

OTHER INFORMATION

• Effects on Company Operations (eg. Site closed, plant stopped, operations interrupted):

• List Authorities involved and action taken by them:

• LIst any media coverage:

INVESTIGATION DETAILS

• Name of person investigating this event:

  Sign

• Enter Position

  Select Project Manager Project Superintendent Safety Manager Safety Advisor Engineer Supervisor Leading Hand Employee Contractor

  • Project Manager
  • Project Superintendent
  • Safety Manager
  • Safety Advisor
  • Engineer
  • Supervisor
  • Leading Hand
  • Employee
  • Contractor

• What investigations have commenced and people involved?

• Additional Information / Supporting documentation:

• Sketch diagram if required

  Drawing

• Add photo if required

  Media

• Add photo if required

  Media

• Add photo if required

  Media

• Add photo if required

  Media

• Add photo if required

  Media

APPROVAL / MANAGEMENT REVIEW

• Name of person reporting this event:

  Sign

• Enter Position

  Select Project Manager Project Superintendent Safety Manager Safety Advisor Engineer Supervisor Leading Hand Employee Contractor

  • Project Manager
  • Project Superintendent
  • Safety Manager
  • Safety Advisor
  • Engineer
  • Supervisor
  • Leading Hand
  • Employee
  • Contractor

• Select date

  Date