Incident Notification Form

Information

Document No.
Audit Title
Client / Site
Conducted on
Prepared by
Location
Personnel

Cintellate Incident Number:

1. Notification Owner Details

Select date
Reported to (LCPL Staff only):
Reported by:
Job Title (if not LCPL):
Non Employee type (if not LCPL):
Company Name (if not LCPL):
Incident Date/Time:
Responsible Entity/Project Site:
Area:

2. Notification Details

Exact Location:
Incident Summary (brief):
What happened?
What could have happened?
Explain what could have happened?
Activity:
Essentials Category:
High Risk Activity?
ARM Reference Number:
Responsible Supervisor:
Send Incident Alert?
Is this a work related incident?
Justification if not work related:
- community injury
- member of public
- exposure/ event outside work environment
- voluntary/ non-work participant/activity
- personal tasks outside of assigned workers
- non-communicable disease/illness
- non-work related mental/ psychological illness
- other
Immediate actions taken: ( detail of actions, completed by & completion date)

3. Incident Type/ Consequence

Personal Damage Near Miss

4. Incident consequence specific details

4.1 Personal damage actual or near miss

Details of Injured Person:
Name:
Department:
Job Title/ Occupation:
Employment Type:
Company Name:
Summary of Injury/ Illness:
Additional injury details:
Initial treatment:
Injury Type and Classification
Where did the injury occur:
Severity of Injury:
- Fatality
- LTI
- RWI
- MTI
- FAI
- Minor
Actual
Class 1: Fatal or Permanent damage to a person(s)
Class 2: Lost time or Restricted work injury, Medically treated
Class 3: First Aid or Minor injury
Potential
Potential Class 1: Any injury that has potential to result in Class 1 damage
Potential Class 2: Any injury that has the potential to result in Class 2 damage
Potential Class 3: Any incident that has the potential to result in Class 3 damage
Details of Injury/ Illness
Shift / Working hours details:
Type of employment
Shift start time
Roster Arrangement
Consecutive days worked:
Average daily hours:
Proportion shift worked:
Workers experience in task (in months):
Date of return to full duties:
Comments:
Hours awake:
Sleep opportunities
Hours of sleep in the last 24 hours:
- 1 hour
- 2 hours
- 3 hours
- 4 hours
- 5 hours
- 6 hours
- 7 hours
- 8 hours or more
Hours of sleep within 24 to 48 hours:
- 1 hour
- 2 hours
- 3 hours
- 4 hours
- 5 hours
- 6 hours
- 7 hours
- 8 hours or more

4.1a Plant / Equipment Damage or Failure

Damage
Failure
Mobile
Fixed
Plant Equipment Type:
Damage Details:
Estimated Value:
Damaged / Failed Equiment
Type/Model:
Year:
Serial No:
Owner Details:
Registration Number:
Asset Number:
Plant/Equipment:
Total Value of Plant/Equipment($):
Actual Cost of Damage ($):

4.1 Personal damage actual or near miss

Details of Injured Person:
Name:
Department:
Job Title/ Occupation:
Employment Type:
Company Name:
Summary of Injury/ Illness:
Additional injury details:
Initial treatment:
Injury Type and Classification
Where did the injury occur:
Severity of Injury:
- Fatality
- LTI
- RWI
- MTI
- FAI
- Minor
Actual
Class 1: Fatal or Permanent damage to a person(s)
Class 2: Lost time or Restricted work injury, Medically treated
Class 3: First Aid or Minor injury
Potential
Potential Class 1: Any injury that has potential to result in Class 1 damage
Potential Class 2: Any injury that has the potential to result in Class 2 damage
Potential Class 3: Any incident that has the potential to result in Class 3 damage
Details of Injury/ Illness
Shift / Working hours details:
Type of employment
Shift start time
Roster Arrangement
Consecutive days worked:
Average daily hours:
Proportion shift worked:
Workers experience in task (in months):
Date of return to full duties:
Comments:
Hours awake:
Sleep opportunities
Hours of sleep in the last 24 hours:
- 1 hour
- 2 hours
- 3 hours
- 4 hours
- 5 hours
- 6 hours
- 7 hours
- 8 hours or more
Hours of sleep within 24 to 48 hours:
- 1 hour
- 2 hours
- 3 hours
- 4 hours
- 5 hours
- 6 hours
- 7 hours
- 8 hours or more

4.1a Plant / Equipment Damage or Failure

Damage
Failure
Mobile
Fixed
Plant Equipment Type:
Damage Details:
Estimated Value:
Damaged / Failed Equipment
Type/Model:
Year:
Serial No:
Owner Details:
Registration Number:
Asset Number:
Plant/Equipment:
Total Value of Plant/Equipment($):
Actual Cost of Damage ($):

4.2 Environmental Damage Actual or Near Miss

Environmental Details
Impact Loss / Type
- HER- Aboriginal and European Culture Heritage
- CON- Contamination to Land & Groundwater
- WAT- Discharge to Surface Waters
- FF- Flora and Fauna
- AIR- Dust, Odour & Emissions
- NVL- Noise and Vibration
- WAS- Waste (Solids, Liquids, Hazardous and non-hazardous)
- RES- Imact on Availablility of Resources
- ESC- Erosion and Sediment
- ASS- Acids Sulphates Soils
- DMR- Dirt and Mud on Public Roads
Details of Environmental Impact:
Estimated Damage/Repair Cost ($):
Was this a compliant?
Actual
Level 1: Extreme incident, where impact is irreversible or reversible but material to LCPL
Level 2: Serious incident, where impact is reversible but costly
Level 3: Minor incident that have a short term and reversible impact on the environment
Potential
Potential Level 1: Any injury that has potential to result in Level 1 damage
Potential Level 2: Any injury that has the potential to result in Level 2 damage
Potential Level 3: Any incident that has the potential to result in Level 3 damage
HER- Aboriginal and European Culture Heritage Details
Indigenous
Non-Indigenous
Incident Type:
Cultural/Archaeological Site Name:
Known Site
Unknown Site
Site Type:
- Archaeological Sites
- Buildings
- Burials
- Campsite (shell scatters)
- Cemeteries
- Dwellings
- Gardens
- Human Remains
- Landscapes
- Rock Art
- Scar Tree
- Stone Arrangement
- Structures
Other Site Type:
Size of Impact Area:
Unit:
CON- Contamination to Land & Groundwater Details
Contaminant:
Land Type:
Volume Released:
Unit:
Volume Recovered:
Unit:
Size of Impact Area:
Unit:
Distance to Sensitive Area:
Unit:
WAT- Discharge to Surface Waters Details
Contaminant:
Volume Released:
Unit:
Distance to Sensitive Area:
Unit:
FF- Flora and Fauna Details
Significance:
- Endangered Species
- Introduced Species
- Native Species
- Priority Species
- Threatened Habitat
- Threatened Species
Fauna
Flora
Cause of Death:
- Blasting
- Clearing and Grubbing
- Entrapment
- Fire
- Natural
- Poison
- Road Kill
Other Cause of Death:
Species Type:
Population/ Size Affected:
Unit:
AIR- Dust, Odour & Emissions
Emission Source:
- Dust
- Fire
- Generator
- Odour
- Refrigerant Gas
- Vehicle Emissions
Other Source Type:
Release Amount:
Unit:
Release Duration (hours):
Report Trigger:
Other, please specify:
Cause:
Did this result from unauthorized use?
NVL- Noise and Vibration Details
Noise Source:
- Blasting
- Excavation
- Fixed Plant
- Mobile Equipment
- Piling
- Tunnelling
Other Source Type:
Noise Limit Exceeded by (dB):
Was this out of approved operational hours?
Vibration Source:
Was this out of approved operational hours?
WAS- Waste (Solids, Liquids, Hazardous and Non- harzardous)
Solid
Liquid
Waste Type:
- Asbestos
- Biological
- Construction/Demolition
- Green Waste
- Hazardous Substance
- Hydrocarbon Contamination
Other Waste Type:
Unauthorised Disposal Location:
Estimated Quantity:
Unit:
Cause:
Able to Recover Waste?
RES- Impact on Availability of Resources Details
Unauthorised Discharge Details
Water Source:
Other Source Type:
Volume:
Unit:
Water Quality:
- TSS > Threshold
- Hyper Saline
- Portable
- Saline
- Hydrocarbon Contaminated
- Turbidity
Ground Water license Limit Exceeded:
Unauthorised Land / Fuel / Waste Details
Describe the Unauthorised Use:
Quantity Used/Affected:
Unit:
Cause:
ESC- Erosion & Sediment Details
Overflow
Discharge
Off-Site
On-Site
Water Quality:
- TSS > Threshold
- Hyper Saline
- Portable
- Saline
- Hydrocarbon Contaminated
- Turbidity
Volume Released:
Unit:
Volume Recovered:
Unit:
Receiving Environment:
Distance to Sensitive Area (Meters):
ASS- Acid Sulphate Soils
Overflow
Discharge
Off-Site
On-Site
Water Quality:
Volume Released:
Unit:
Volume Recovered:
Unit:
Receiving Environment:
Distance to Sensitive Area (Meters):
DMR- Dirt and Mud on Public Roads
Off-Site
On-Site
Nature of Material:
Area Impacted:
Unit:
Area Remediated:
Unit:
Receiving Environment:
Distance to Sensitive Area (Meters):
Environmental Damage Actual

4.2 Environmental Damage Actual or Near Miss

Environmental Details
Impact Loss / Type
- HER- Aboriginal and European Culture Heritage
- CON- Contamination to Land & Groundwater
- WAT- Discharge to Surface Waters
- FF- Flora and Fauna
- AIR- Dust, Odour & Emissions
- NVL- Noise and Vibration
- WAS- Waste (Solids, Liquids, Hazardous and non-hazardous)
- RES- Imact on Availablility of Resources
- ESC- Erosion and Sediment
- ASS- Acids Sulphates Soils
- DMR- Dirt and Mud on Public Roads
Details of Environmental Impact:
Estimated Damage/Repair Cost ($):
Was this a compliant?
Actual
Level 1: Extreme incident, where impact is irreversible or reversible but material to LCPL
Level 2: Serious incident, where impact is reversible but costly
Level 3: Minor incident that have a short term and reversible impact on the environment
Potential
Potential Level 1: Any injury that has potential to result in Level 1 damage
Potential Level 2: Any injury that has the potential to result in Level 2 damage
Potential Level 3: Any incident that has the potential to result in Level 3 damage
HER- Aboriginal and European Culture Heritage Details
Indigenous
Non-Indigenous
Incident Type:
Cultural/Archaeological Site Name:
Known Site
Unknown Site
Site Type:
- Archaeological Sites
- Buildings
- Burials
- Campsite (shell scatters)
- Cemeteries
- Dwellings
- Gardens
- Human Remains
- Landscapes
- Rock Art
- Scar Tree
- Stone Arrangement
- Structures
Other Site Type:
Size of Impact Area:
Unit:
CON- Contamination to Land & Groundwater Details
Contaminant:
Land Type:
Volume Released:
Unit:
Volume Recovered:
Unit:
Size of Impact Area:
Unit:
Distance to Sensitive Area:
Unit:
WAT- Discharge to Surface Waters Details
Contaminant:
Volume Released:
Unit:
Distance to Sensitive Area:
Unit:
FF- Flora and Fauna Details
Significance:
- Endangered Species
- Introduced Species
- Native Species
- Priority Species
- Threatened Habitat
- Threatened Species
Fauna
Flora
Cause of Death:
- Blasting
- Clearing and Grubbing
- Entrapment
- Fire
- Natural
- Poison
- Road Kill
Other Cause of Death:
Species Type:
Population/ Size Affected:
Unit:
AIR- Dust, Odour & Emissions
Emission Source:
- Dust
- Fire
- Generator
- Odour
- Refrigerant Gas
- Vehicle Emissions
Other Source Type:
Release Amount:
Unit:
Release Duration (hours):
Report Trigger:
Other, please specify:
Cause:
Did this result from unauthorized use?
NVL- Noise and Vibration Details
Noise Source:
- Blasting
- Excavation
- Fixed Plant
- Mobile Equipment
- Piling
- Tunnelling
Other Source Type:
Noise Limit Exceeded by (dB):
Was this out of approved operational hours?
Vibration Source:
Was this out of approved operational hours?
WAS- Waste (Solids, Liquids, Hazardous and Non- harzardous)
Solid
Liquid
Waste Type:
- Asbestos
- Biological
- Construction/Demolition
- Green Waste
- Hazardous Substance
- Hydrocarbon Contamination
Other Waste Type:
Unauthorised Disposal Location:
Estimated Quantity:
Unit:
Cause:
Able to Recover Waste?
RES- Impact on Availability of Resources Details
Unauthorised Discharge Details
Water Source:
Other Source Type:
Volume:
Unit:
Water Quality:
- TSS > Threshold
- Hyper Saline
- Portable
- Saline
- Hydrocarbon Contaminated
- Turbidity
Ground Water license Limit Exceeded:
Unauthorised Land / Fuel / Waste Details
Describe the Unauthorised Use:
Quantity Used/Affected:
Unit:
Cause:
ESC- Erosion & Sediment Details
Overflow
Discharge
Off-Site
On-Site
Water Quality:
- TSS > Threshold
- Hyper Saline
- Portable
- Saline
- Hydrocarbon Contaminated
- Turbidity
Volume Released:
Unit:
Volume Recovered:
Unit:
Receiving Environment:
Distance to Sensitive Area (Meters):
ASS- Acid Sulphate Soils
Overflow
Discharge
Off-Site
On-Site
Water Quality:
Volume Released:
Unit:
Volume Recovered:
Unit:
Receiving Environment:
Distance to Sensitive Area (Meters):
DMR- Dirt and Mud on Public Roads
Off-Site
On-Site
Nature of Material:
Area Impacted:
Unit:
Area Remediated:
Unit:
Receiving Environment:
Distance to Sensitive Area (Meters):
Non SHE Event Only (Operational)

4.3 Non SHE Event Only (Operational)

Select date
Reference Number:
Notified to (LCPL Staff only):
Notified By:
Job Title (if not LCPL):
Non Employee type:
Company Name:
Detailed justification as to why no potential risk is perceived to have occurred:
Non SHE Event Type:
- Company Reputation
- Criminal Behavior/Security
- Operational Delay
- Non LCPL related Event/condition
- Non loss of control - non hazardous service contact
- Process/Production Loss
- Plant/Equipment Damage
- Plant/Equipment Failure
- Property Damage by Weater / Nature / Environmental Conditions
- Social Responsibility
Other, please specify:
Damage Details:
Mobile
Fixed
Estimated Value:
Serial Number:
Plant/Vehicle Operator:
Registration Number:
Asset Number: