Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Incident details

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

  • Time and Date reported?

  • Who reported the damage?

  • Time and Date on site?

  • Work pack number?

  • Work Pack number. If not a reactive number.

  • Incident address/location

  • Incident details/description

  • DAMAGED ASSETT DESCRIPTION.

  • What utilities were damaged?

  • Damaged asset description?

  • What was the result of the damage?

  • ELECTRIC SHOCK?

  • 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?

  • 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?

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

  • Was the electrical access permit filled out correctly?

  • Was the confined space permit filled out correctly?

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

  • Was all other required documentation filled out correctly?

  • IMAGES OF INCIDENT/DAMAGE

  • Please ensure all images cover the following-

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

  • The incident site with recognisable landmarks?

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

  • Work site traffic control measures?

  • Diagram of incident location

  • Diagram of incident location- 2

  • DETAILS OF PERSON RESPONSIBLE FOR DAMAGE

  • Name?

  • Address?

  • Vehicle registration number?

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

  • Contact Details?

  • Other information?

  • WITNESSES DETAILS

  • Name, witness 1

  • Address, witness 1

  • Contact details, witness 1

  • Name, witness 2

  • Address, witness 2

  • Contact details, witness 2

  • POLICE DETAILS.

  • Police officers name.

  • Badge number.

  • Police report number.

  • EMPLOYEES AND PLANT UTILISED ON SITE?

  • Person 1, and role? (site supervisor)

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

  • Person 2, and role?

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

  • Person 3, and role?

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

  • Person 4, and role?

  • List of plant/vehicles used on site?

  • OTHER INFORMATION RELEVANT TO SITE.

  • 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?

  • What state/condition was the site left in?

  • Signature of report writer upon completion of report.

  • Name and Signature of site supervisor.

  • Time and date of the completion of report

  • Time and date of the end of travel

  • Time and date of new job allocation.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.