Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Incident details
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Time and Date the damage was reported to the dispatch centre.
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Time and Date reported?
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Who reported the damage?
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Time and Date on site?
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Work pack number?
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Work Pack number. If not a reactive number.
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Incident address/location
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Incident details/description
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DAMAGED ASSETT DESCRIPTION.
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What utilities were damaged?
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Damaged asset description?
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What was the result of the damage?
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ELECTRIC SHOCK?
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Electric shock recipient name and details.
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Location of the electrical shock. (e.g. Shower)
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Clothing of the electrical shock recipient. (e.g. Shower)
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Installation type?
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Shock location description.
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What equipment, appliance or plant were involved in the electric shock.
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What tests were carried out, where and test results. (e.g. Polarity test at the point of attachment)
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After all tests are completed, what is the concluded cause of the reported electric shock.
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ON SITE DOCUMENTATION?
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Was the 'hazard Risk Assessment', filled out correctly?
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Was the electrical access permit filled out correctly?
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Was the confined space permit filled out correctly?
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We're all SWMS and procedures available on site?
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Was all other required documentation filled out correctly?
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IMAGES OF INCIDENT/DAMAGE
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Please ensure all images cover the following-
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The damage to assets, plant ,equipment and PPE?
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The incident site with recognisable landmarks?
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Responsible party’s plant/vehicle, that caused the damage?
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Work site traffic control measures?
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Diagram of incident location
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Diagram of incident location- 2
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DETAILS OF PERSON RESPONSIBLE FOR DAMAGE
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Name?
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Address?
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Vehicle registration number?
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Employed by? (if incident occurred during their normal work duties)
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Contact Details?
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Other information?
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WITNESSES DETAILS
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Name, witness 1
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Address, witness 1
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Contact details, witness 1
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Name, witness 2
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Address, witness 2
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Contact details, witness 2
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POLICE DETAILS.
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Police officers name.
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Badge number.
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Police report number.
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EMPLOYEES AND PLANT UTILISED ON SITE?
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Person 1, and role? (site supervisor)
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If this persons role required a license, what license is held and what is their license number?
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Person 2, and role?
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If this persons role required a license, what license is held and what is their license number?
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Person 3, and role?
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If this persons role required a license, what license is held and what is their license number?
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Person 4, and role?
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List of plant/vehicles used on site?
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OTHER INFORMATION RELEVANT TO SITE.
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Other information relevant to the damage?
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List of equipment used to make repairs?
WORK COMPLETION DETAILS
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What state/condition was the site left in when the report writer left site?
- Restored and safe
- Isolated and safe
- Restored and barricaded
- Isolated and barricaded
- Undergoing repairs
- Hand-over to new work crew
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What state/condition was the site left in?
- Restored and safe
- Isolated and safe
- Restored and barricaded
- Isolated and barricaded
- Undergoing repairs
- Hand-over to new work crew
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Signature of report writer upon completion of report.
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Name and Signature of site supervisor.
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Time and date of the completion of report
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Time and date of the end of travel
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Time and date of new job allocation.