Page 1: Incident / NCR Details
-
Incident / NCR Report No.
-
Location
-
Conducted on
-
Client / Contractor
-
On site representative (Client / Contractor)
-
Project name
-
Town or Suburb
-
Road / Place
-
Reported by
-
Employer
-
Mobile No.
Page 2: Personnel Details
-
Incident type
- Work related illness / injury
- Plant / equipment damage
- Environment
- NCR
- Near miss / hazard
- Complaint
- Improvements / requests for change
- Other
-
Name of person involved
-
Employer
-
Mobile No.
-
"MEDICAL TREATMENT" required
- None
- First aid
- Doctor
- Hospital
-
Suspected injury
-
Was a "DRUG / ALCOHOL TEST" taken.
-
Did the person have to "CEASE WORK" for the remainder of the day
-
Which "AUTHORITIES" were notified or attended site
- Police
- Ambulance
- Fire
- EPA
- Client
-
Is this a "WHS Notifiable Incident"
-
Has the WHS Division been called on 1300 362 128
-
Name of witness
-
Employer
-
Mobile No.
Page 3: Incident investigation
-
Has a FIXIT no. been created
-
FIXIT no.
-
Describe what happened
-
Have photographs been taken
-
HOW did it occur & WHY do you think it happened?
-
Risk matrix
-
What was the LIKELIHOOD of the incident occurring?
-
What was the CONSEQUENCE of the incident occurring?
-
What is the RISK score?
-
What was the ROOT cause?
-
What IMMEDIATE action was taken to isolate the HAZARD?
Page 4: Corrective Action
-
What CORRECTIVE action was carried out to prevent the incident from re-occurring
-
What PREVENTATIVE action is in place to prevent the incident from re-occurring
-
Risk matrix
-
What is the LIKELIHOOD of the incident re-occurring post CORRECTIVE & PREVENTATIVE actions being put into place
-
What is the CONSEQUENCE of the incident re-occurring post CORRECTIVE & PREVENTATIVE actions being put into place
-
What is the new RISK score
-
Is the new RISK score acceptable
Page 5: Sign Off
-
Has the FIXIT been closed out
-
Is the Incident / NCR investigation complete
-
Investigation signed off
-
Client / Management sign off
-
Notes
