Incident Report

• Conducted on

  Date

• Prepared by

• Location
  Address

Classification

• what type of incident

  Select LTI MTI FAI Hazard Near Hit/miss Property Damage Equipment Damage Production Loss Non Conformance Security Environment Community Impact Other

  • LTI
  • MTI
  • FAI
  • Hazard
  • Near Hit/miss
  • Property Damage
  • Equipment Damage
  • Production Loss
  • Non Conformance
  • Security
  • Environment
  • Community Impact
  • Other

• what type of personal injury

  LTI

  MTI

  FAI

  Illness

  N/A

Incident Details

• Select date

  Date
• Add location
  Address

Reported by

• Name

• Select date

  Date
• Add location
  Address

Reported to

• Name

• Select date

  Date

Person involved in incident or injured person

• name of person involved

• what type of work was being preformed

• what shift type

  Day

  Night

• Shift Length:

  Select 8hrs 10hrs 12hrs other

  • 8hrs
  • 10hrs
  • 12hrs
  • other

• start time

  Date

• Total experience in task

  Select < 1 Mth 1-3 Mths 4 Mths – 1 yr > 1yr

  • < 1 Mth
  • 1-3 Mths
  • 4 Mths – 1 yr
  • > 1yr

• Employment Status

  Select Full Time Part Time Casual Other

  • Full Time
  • Part Time
  • Casual
  • Other

• Employer Details

  Select A Dart & Co Contractor other

  • A Dart & Co
  • Contractor
  • other

• Contractor name or other

• . Supervisor of Person involved

• Training

  Select site induction construction card procedure training working at heights EWP earthmoving machine other

  • site induction
  • construction card
  • procedure training
  • working at heights
  • EWP
  • earthmoving machine
  • other

• other training

• Description of Incident / Injury

• Witnesses

IMMEDIATE ACTIONS

• What actions where taken to care for the injured and to make safe

• All Incidents (excluding minor first aid) are notifiable to the relevant supervisor / Project Manager / Safety Manager and should be done as soon as practical after the occurrence of the incident.

Nature of Injury

• what type of injury

  Select Abrasions Amputation Asphyxia Bruising Burns Crush Dislocation Effects of Chemicals Effects of Exposure Electric Shock Fracture Foreign Body Heat stress Illness Internal Injury Laceration Loss of Consciousness Nausea Puncture Wound Open Wound Sprain Strain Other

  • Abrasions
  • Amputation
  • Asphyxia
  • Bruising
  • Burns
  • Crush
  • Dislocation
  • Effects of Chemicals
  • Effects of Exposure
  • Electric Shock
  • Fracture
  • Foreign Body
  • Heat stress
  • Illness
  • Internal Injury
  • Laceration
  • Loss of Consciousness
  • Nausea
  • Puncture Wound
  • Open Wound
  • Sprain
  • Strain
  • Other

• description of illness or other condition

• Body Location

  Select Back Hip Upper Leg Lower leg Ankle Foot Toes Knee Skull / Head Face Ear Eye Neck Chest Abdomen Groin Shoulder Upper Arm Lower Arm Wrist Hand Fingers Other

  • Back
  • Hip
  • Upper Leg
  • Lower leg
  • Ankle
  • Foot
  • Toes
  • Knee
  • Skull / Head
  • Face
  • Ear
  • Eye
  • Neck
  • Chest
  • Abdomen
  • Groin
  • Shoulder
  • Upper Arm
  • Lower Arm
  • Wrist
  • Hand
  • Fingers
  • Other

• which side

  left

  right

• location of injury on body

• Description of treatment and conditions of Injured Person

• Treatment Outcome

  Select Return to normal duties Suitable duties/Hours Follow-up first aid treatment required Referred for doctor/hospital/medical treatment Workers Compensation Claim Evacuation required

  • Return to normal duties
  • Suitable duties/Hours
  • Follow-up first aid treatment required
  • Referred for doctor/hospital/medical treatment
  • Workers Compensation Claim
  • Evacuation required

• Treatment Provider

• Medical Provider Phone

EQUIPMENT DAMAGE / PRODUCTION LOSS

• is there any equipment damage or production loss

  yes

  no

  N/A

• Estimated costs

  Select $ 0 - $5000 $5001 - $20,000 20,001 - $500,000 $500,001 - $2,000,000 $2,000,000 +

  • $ 0 - $5000
  • $5001 - $20,000
  • 20,001 - $500,000
  • $500,001 - $2,000,000
  • $2,000,000 +

ENVIRONMENTAL IMPACT

• is there an environmental impact

  yes

  no

  N/A

• Impact Categories

  Select Water - Ground Water - Surface Flora Land – Undisturbed Land – Rehabilitated Land – General Culture Heritage Air Quality/ Pollution Fauna Community / Public Other

  • Water - Ground
  • Water - Surface
  • Flora
  • Land – Undisturbed
  • Land – Rehabilitated
  • Land – General
  • Culture
  • Heritage
  • Air Quality/ Pollution
  • Fauna
  • Community / Public
  • Other

• describe environmental impact

• describe environmental impact (Impacted by, quantity, area)

EXTERNAL NOTIFICATION

• Government Agency / Regulatory Authority Notification required<br>

  yes

  no

• Select date

  Date

• agency name

• notified by

• provide photos of incident scene if possible

  Media

• Investigation Required

  yes

  no

• name of person completing form

  Sign