Title Page
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Prepared by
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Documented on
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Worksite
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Location
Incident Details
1. General Information
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Type of Incident
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Date and time of when the incident occurred
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Location of incident (be specific as possible)
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What was the work being done?
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Describe the incident
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Attach or take photo of surrounding environment including any annotations
2. Damages and Injury
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Incident Category
- Injury/ Illness
- Property Damage
- Environmental Incident
- Vehicle Incident
- Fire Incident
- Other
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Please specify
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Attach or take photo evidence of damages and injury (where appropriate)
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Describe in detail
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Attach or take photo evidence of damages or injury (where appropriate)
3. Affected Individual(s)
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Were there people involved in the incident?
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Click + to add affected individual(s)
Person
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Name
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Sex
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Job Title
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How long in this occupation
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Start time
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Hours worked
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Shift arrangement
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Training/ Qualifications
- Induction
- Task specific
- Trade
- None of the above
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Contact Number
4. Witness Statements (if applicable)
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Were there witnesses?
Witness
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Name
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Contact
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Statement
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Witness signature (if applicable)
5. Corrective Actions
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What actions will be taken to eliminate future repeats of the incident? (Assign action to respective member in the organization)
Completion
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Management comments
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Name and signature of reporting person
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Supervisor sign-off