Incident/Damage Report - V2

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Incident details

• Time and Date the damage was reported to the dispatch centre.

  Date

• Time and Date reported?

  Date

• Who reported the damage?

• Time and Date on site?

  Date

• Work pack number?

  Yes

  No

  N/A

• Work Pack number. If not a reactive number.

• Incident address/location

• Incident details/description

• DAMAGED ASSETT DESCRIPTION.

  YES

  NO

• What utilities were damaged?

• Damaged asset description?

• What was the result of the damage?

• ELECTRIC SHOCK?

  YES

  NO

• Electric shock recipient name and details.

• Location of the electrical shock. (e.g. Shower)

• Clothing of the electrical shock recipient. (e.g. Shower)

• Installation type?

  Residential

  commercial

• Shock location description.

• What equipment, appliance or plant were involved in the electric shock.

• What tests were carried out, where and test results. (e.g. Polarity test at the point of attachment)

• After all tests are completed, what is the concluded cause of the reported electric shock.

• ON SITE DOCUMENTATION?

  YES

  NO

• Was the 'hazard Risk Assessment', filled out correctly?

  Yes

  No

  N/A

• Was the electrical access permit filled out correctly?

  Yes

  No

  N/A

• Was the confined space permit filled out correctly?

  Yes

  No

  N/A

• We're all SWMS and procedures available on site?

  Yes

  No

  N/A

• Was all other required documentation filled out correctly?

  Yes

  No

  N/A

• IMAGES OF INCIDENT/DAMAGE

  YES

  NO

• Please ensure all images cover the following-

• The damage to assets, plant ,equipment and PPE?

  Yes

  No

  N/A

• The incident site with recognisable landmarks?

  Yes

  No

  N/A

• Responsible party’s plant/vehicle, that caused the damage?

  Yes

  No

  N/A

• Work site traffic control measures?

  Yes

  No

  N/A

• Diagram of incident location

  Drawing

• Diagram of incident location- 2

  Drawing

• DETAILS OF PERSON RESPONSIBLE FOR DAMAGE

  YES

  NO

• Name?

• Address?

• Vehicle registration number?

• Employed by? (if incident occurred during their normal work duties)

• Contact Details?

• Other information?

• WITNESSES DETAILS

  YES

  NO

• Name, witness 1

• Address, witness 1

• Contact details, witness 1

• Name, witness 2

• Address, witness 2

• Contact details, witness 2

• POLICE DETAILS.

  YES

  NO

• Police officers name.

• Badge number.

• Police report number.

• EMPLOYEES AND PLANT UTILISED ON SITE?

  YES

  NO

• Person 1, and role? (site supervisor)

  Sign

• If this persons role required a license, what license is held and what is their license number?

• Person 2, and role?

  Sign

• If this persons role required a license, what license is held and what is their license number?

• Person 3, and role?

  Sign

• If this persons role required a license, what license is held and what is their license number?

• Person 4, and role?

  Sign

• List of plant/vehicles used on site?

• OTHER INFORMATION RELEVANT TO SITE.

  YES

  NO

• Other information relevant to the damage?

• List of equipment used to make repairs?

WORK COMPLETION DETAILS

• What state/condition was the site left in when the report writer left site?

  Select Restored and safe Isolated and safe Restored and barricaded Isolated and barricaded Undergoing repairs Hand-over to new work crew

  • Restored and safe
  • Isolated and safe
  • Restored and barricaded
  • Isolated and barricaded
  • Undergoing repairs
  • Hand-over to new work crew

• What state/condition was the site left in?

  Select Restored and safe Isolated and safe Restored and barricaded Isolated and barricaded Undergoing repairs Hand-over to new work crew

  • Restored and safe
  • Isolated and safe
  • Restored and barricaded
  • Isolated and barricaded
  • Undergoing repairs
  • Hand-over to new work crew

• Signature of report writer upon completion of report.

  Sign

• Name and Signature of site supervisor.

  Sign

• Time and date of the completion of report

  Date

• Time and date of the end of travel

  Date

• Time and date of new job allocation.

  Date