Information
Hazard / Incident Report - MARKSCON
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Document No.
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Report Made on?
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Site Name / Location:
- 1-3 Moffat St, Brighton
- 956 Doncaster Rd, Doncaster
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Conducted by:
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Date and Time of Occurrence ?
Person Submitting Details
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Date and Time Report is made
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Name of Employee / Contractor
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Position Title
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Telephone Number
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Time of Incident / HAZARD occured
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Manager / Supervisor / Site Manager
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Working Area
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Please ADD photos
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Name of Employer of Injured Person
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Address / Location where Incident Occurred
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Brief Description of the Incident
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THE ABOVE INFORMATION IS TO BE PROVIDED TO THE EXTENT THAT IT IS KNOWN AT THE TIME OF WRITING.
Details of Injured Person(s)
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Details of Person(s) Injured
PERSON
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Name of Person Injured
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Male OR Female
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Residential Address including Postcode
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Occupation / Job Total
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Employee ? Subcontractor ? Member of Public ?
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Work / Activity being undertaken at the Time of Incident ( Identify any Plant, Substance, Equipment Involved)
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Brief Description of Injuries
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Please ADD photos IF possible
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Person(s) who saw Incident or First Came to Scene (Full names, contact phone numbers)
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Action Taken ? Intended, if any, to prevent recurrence of Incident
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Please ADD photos IF required
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THE ABOVE INFORMATION IS TO BE PROVIDED TO THE EXTENT THAT IT IS KNOWN AT THE TIME OF WRITING.
SIGN OFF
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Please ensure this Report is emailed to the following Markscon Personnel:
richard.ingram@marksgroup.com.au -
Employee Representative (HSR) Name & Signature:
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Managers Name & Signature:
