Information

Hazard / Incident Report - MARKSCON

  • Document No.

  • Report Made on?

  • Business Group

  • Store Location

  • Conducted by:

  • Date and Time of Occurrence ?

Person Submitting Details

  • Date and Time Report is made

  • Name of Employee

  • Position Title

  • Telephone Number

  • Time of Incident / HAZARD occured

  • Manager / Supervisor / Site Manager

  • Working Area

  • Please ADD photos

  • Name of Employer of Injured Person

  • Address / Location where Incident Occurred

  • Brief Description of the Incident

  • THE ABOVE INFORMATION IS TO BE PROVIDED TO THE EXTENT THAT IT IS KNOWN AT THE TIME OF WRITING.

Details of Incident / Accident

  • TYPE of incident / accident

  • Please given detailed description of the incident or accident

  • ADD photos if required

Details of Injured Person(s)

  • Was a person or persons injured?<br>If yes please continue filling in the details below.

  • Details of Person(s) Injured

  • PERSON
  • Name of Person Injured

  • Male OR Female

  • Residential Address including Postcode

  • Occupation / Job Total

  • Employee ? Subcontractor ? Member of Public ?

  • Work / Activity being undertaken at the Time of Incident ( Identify any Plant, Substance, Equipment Involved)

  • Brief Description of Injuries

  • Please ADD photos IF possible

  • Person(s) who saw Incident or First Came to Scene (Full names, contact phone numbers)

  • Action Taken ? Intended, if any, to prevent recurrence of Incident

  • Please ADD photos IF required

  • THE ABOVE INFORMATION IS TO BE PROVIDED TO THE EXTENT THAT IT IS KNOWN AT THE TIME OF WRITING.

SIGN OFF

  • Please ensure this Report is emailed to the following Marks Group Industries Personnel:
    richard.ingram@marksgroup.com.au

  • Name & Signature of Person completing this report:

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