QSEMS-FRM-0222 - Inciden Report Form
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Site
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Date
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Prepared by
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Location
Incident Report Form
PART A: INCIDENT DETAILS
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Location of Incident:
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Incident Classification
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Reportable To Regulator (Office Use Only)
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Involved/ Injured Person
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Position Title
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Date of Birth (dd/mm/yy):
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Incident Time / Date
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Reported By
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Time / Date Reported
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Reported To
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Witness/s
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Employment Status
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If Contractor - Company Name
Environmental Incident
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Environmental Incident Detail (If Relevant)
Damaged Plant / Equipment Detail (If Relevant)
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ID/Rego #
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Type
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Make
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Model
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Hours / Kms
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Year of Manufacture
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Description of Damage
Nonconformance
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Nonconformance Detail (If Relevant)
Injury or Illness Detail (if Relevent)
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Initial Response
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Is this a Recurrence of a previous injury?
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Mechanism
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Agency
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Nature of Injury
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Bodily Location
Incident Summary
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Activity being undertaken at the time of the incident?
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Describe what happened (including brief description of any injury/damage or environmental harm sustained)
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What immediate corrective actions were taken (and by whom)
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Actual Risk Score
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Potential Risk Score
PART B - TO BE COMPLETED BY THE SUPERVISOR
CAUSAL FACTORS
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Human Factors
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Machine Factors
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System Factors
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Environmental Factors
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List any other known contributing factors or physical hazards
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How did the factors you have ticked off above contribute / cause the incident / why have you selected those factors
Supervisor
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Print name
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Signature
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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
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Are the proposed Corrective/Preventive Actions adequate?
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Project/Operations Manager Signature
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Print name
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Date
MANAGING DIRECTOR – ALL HIGH / CRITICAL RISK INCIDENTS
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Have the necessary investigations or evaluations been completed?
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Have corrective actions controlled risk to acceptable level?
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Date
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Sign
HSEQ Manager Review - All Incidents
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Have corrective actions controlled risk to acceptable level?
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Has an Internal Safety Alert been issued?
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Print name
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Signature
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Date
PART E - Optional
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ADDITIONAL COMMENTS