Incident Report form - duplicate

• Site

• Date

  Date

• Prepared by

• Location

PART A: INCIDENT DETAILS (TO BE COMPLETED WITH INVOLVED / INJURED PER)SON BY SUPERVISOR)

• Location of Incident:

• Incident Classification

  Select

• Reportable To Regulator (Office Use Only)

  Yes

  No

  N/A

• Involved/ Injured Person

• Position Title

• Date of Birth (dd/mm/yy):

  Date

• Incident Time / Date

  Date

• Reported By

• Time / Date Reported

  Date

• Reported To

• Witness/s

• Employment Status

  Select

• If Contractor - Company Name

Environmental Incident

• Environmental Incident Detail (If Relevant)

  Select

Damaged Plant / Equipment Detail (If Relevant)

• ID/Rego #

• Type

• Make

• Model

• Hours / Kms

• Year of Manufacture

• Description of Damage

Nonconformance

• Nonconformance Detail (If Relevant)

  Select

Injury or Illness Detail (if Relevent)

• Initial Response

  Select

• Is this a Recurrence of a previous injury?

  Yes

  No

  N/A

• Mechanism

  Select

• Agency

  Select

• Nature of Injury

  Select

• Bodily Location

  Select

Incident Summary

• Activity being undertaken at the time of the incident?

• Describe what happened (including brief description of any injury/damage or environmental harm sustained)

• What immediate corrective actions were taken (and by whom)

• Actual Risk Score

  Select

• Potential Risk Score

  Select

PART B - TO BE COMPLETED BY THE SUPERVISOR

CAUSAL FACTORS

• Human Factors

  Select

• Machine Factors

  Select

• System Factors

  Select

• Environmental Factors

  Select

• List any other known contributing factors or physical hazards

• How did the factors you have ticked off above contribute / cause the incident / why have you selected those factors

Supervisor

• Print name

• Signature

  Sign

• Date

  Date

PART C - REVIEWS & APPROVALS (ALL sections below to be completed for Personal Harm Incidents – Regardless of level of Risk)

PROJECT/OPERATIONS MANAGER – FOR ALL INCIDENTS

• Are the proposed Corrective/Preventive Actions adequate?

  Yes

  No

  N/A

• Project/Operations Manager Signature

  Sign

• Print name

• Date

  Date

MANAGING DIRECTOR – ALL HIGH / CRITICAL RISK INCIDENTS

• Have the necessary investigations or evaluations been completed?

  Yes

  No

  N/A

• Have corrective actions controlled risk to acceptable level?

  Yes

  No

  N/A

• Date

  Yes

  No

  N/A

• Sign

  Yes

  No

  N/A

HSEQ Manager Review - All Incidents

• Have corrective actions controlled risk to acceptable level?

  Yes

  No

  N/A

• Has an Internal Safety Alert been issued?

  Yes

  No

  N/A

• Print name

• Signature

  Sign

• Date

  Date

PART E - Optional

• ADDITIONAL COMMENTS