QSEMS-FRM-0222 - Inciden Report Form

  • Site

  • Date

  • Prepared by

  • Location

QSEMS-FRM-0222 - Incident Report Form

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

  • Location of Incident:

  • Incident Classification

  • Reportable To Regulator (Office Use Only)

  • Involved/ Injured Person

  • Position Title

  • Date of Birth (dd/mm/yy):

  • Incident Time / Date

  • Reported By

  • Time / Date Reported

  • Reported To

  • Witness/s

  • Employment Status

  • If Contractor - Company Name

Environmental Incident

  • Environmental Incident Detail (If Relevant)

Damaged Plant / Equipment Detail (If Relevant)

  • ID/Rego #

  • Type

  • Make

  • Model

  • Hours / Kms

  • Year of Manufacture

  • Description of Damage

Nonconformance

  • Nonconformance Detail (If Relevant)

Injury or Illness Detail (if Relevent)

  • Initial Response

  • Is this a Recurrence of a previous injury?

  • Mechanism

  • Agency

  • Nature of Injury

  • Bodily Location

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

  • Potential Risk Score

PART B - TO BE COMPLETED BY THE SUPERVISOR

CAUSAL FACTORS

  • Human Factors

  • Machine Factors

  • System Factors

  • Environmental Factors

  • 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

  • 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?

  • Project/Operations Manager Signature

  • Print name

  • Date

MANAGING DIRECTOR – ALL HIGH / CRITICAL RISK INCIDENTS

  • Have the necessary investigations or evaluations been completed?

  • Have corrective actions controlled risk to acceptable level?

  • Date

  • Sign

HSEQ Manager Review - All Incidents

  • Have corrective actions controlled risk to acceptable level?

  • Has an Internal Safety Alert been issued?

  • Print name

  • Signature

  • Date

PART E - Optional

  • ADDITIONAL COMMENTS

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