INCIDENT - ACCIDENT CHECKLIST APPLE IOS VERSION

• Conducted on

  Date

• Reporter's Name & Company Represented:

• Location
  Address

WORKS AREA / TEAM DETAILS

• Company Involved

• LCRA Borough PERMIT no

• Works Team Name / Reference

• Team Leader's Name:

• NGE - Site Controller Name

INCIDENT, ACCIDENT, DETAILS

• Person Involved - Details + Phone Number

• Further Persons Involved - Details + Phone Number

• Were there Injuries to Persons / Environmental Damage

  Yes

  No

  N/A

• Requires Immediate Attention / Action

  Yes

  No

  N/A

• Details of measures put in place

PRESENT WITNESSES

• Was there any witnesses to the Incident / Accident?

  Yes

  No

  N/A

• Witness Name

• Witness Contact Information

• Witness Description of Events

• Witness Signature

  Sign

NEXT STEPS

• Incident / Accident SEVERITY Level

  LOW

  MEDIUM

  HIGH

• Investigation Required?

  Yes

  No

  N/A

• Has Incident / Accident been reported to NGE Site Controller

  Yes

  No

  N/A

• Name of NGE Site Controller

CLOSE OUT

• Signature:

  Sign

Sheet