Interim Event Notification Report V2

• To be submitted to Regional Operations Manager and cc to Regional Safety Advisor

• Client / Site

General Information

• Document No.

• Date

  Date
• Location
  Address

Contractor Information

• Contractor

• Contractor Supervisor / Foreman

• Contractor Contact Number

• Company details: (address, phone etc)

Service Provider details (if different from above)

• Contract Supervisor / Field Manager

• Company details: (address, phone etc)

• Applicable?

  Yes

  No

Injured Person/s

• Name

• Date of Birth

• Address

• Contact Number

Witnesses

• Name

• Date of Birth

• Address

• Contact Number

Event Type

• Damage

• Injury

• Environmental

• Near Miss

• Safety Critical Strike

• Non Safety Critical Strike

• Member of Public

• Other (state details below)

• Details

Event Description

• Brief details of Event (basic facts only about the event)

Immediate Action taken

• Details of Action 1

• By whom

• Verified by (Chorus Nominee )

• Details of Action 2

• By whom

• Verified by (Chorus Nominee )

• Details of Action 3

• By whom

• Verified by (Chorus Nominee )

• Details of Action 4

• By whom

• Verified by (Chorus Nominee )

Photos of Event / Site

• Add media

  Media

• Which of the following were in place at the time of the Event? (Copies or photographs to be obtained )

Standard Operating Procedures

• Working at height

• Add media

  Media

• Working with asbestos

• Add media

  Media

• Working in the vicinity of vehicular traffic

• Add media

  Media

• Working with utility services

• Add media

  Media

• Working in confined space

• Add media

  Media

• Work around mobile plant

• Add media

  Media

• Excavation works

• Add media

  Media

• Driver alertness

• Add media

  Media

• Electrical works

• Add media

  Media

• Other. State details below

• Details

• Add media

  Media

Risk Assessment

• Safe work method statement

• Add media

  Media

• Site specific (JSA, daily pre start)

• Add media

  Media

• Plant (should be inside cab)

• Add media

  Media

• Other. State details below

• Details

• Add media

  Media

Permits / Consents

• Working at height permit

• Add media

  Media

• Confined space entry permit

• Add media

  Media

• Excavation, drilling permit

• Add media

  Media

• Dial B4U DIG

• Add media

  Media

• Transformer permit

• Add media

  Media

• International cables permit

• Live electrical works

• Add media

  Media

• Work access permit / Corridor access request

• Add media

  Media

• Close approach consent (pole)

• Global tree consent

• Add media

  Media

• Close proximity consent (Overhead )

• Add media

  Media

• Other. State details below

• Details

• Add media

  Media

Training Competencies

• Working at height

• STMS

• Add media

  Media

• Wheels, tracks and rollers

• Add media

  Media

• Induction ID

• Add media

  Media

• Confined space entry

• Add media

  Media

• Traffic Controller

• Add media

  Media

• What level?

• Drivers licence

• Add media

  Media

• Site Safe tele. Passport

• Add media

  Media

• Other. State details below

• Details

• Add media

  Media

• Mandatory questions to be completed by Chorus Nominee

Questions

• What applicable safety rules / written procedures were communicated to the employee.? How were they enforced?

• What supervision was in place at the time of the event? And how experienced were they?

• What training was given to the individual in how to undertake the task? When and is still valid?

• How were site specific hazards identified (verify daily pre start /jsa)? Were safety critical risks identified and control measures in place? (copy to be obtained )

• What control measures (elimination, isolation, minimise - EIM) were they taken / not taken (look at daily pre start or SHEWMS)

• Had a daily plant pre start been completed by the plantv operator prior to operating the plant? (copy to be obtained)

• Had the methodology of the task changed from the start of the shift e.g. decision to drill instead of trench - If so how was this communicated amonst the crew? (we are looking for new risks, how were they managed?)

• Was there reasonable cause testing required? (drug and alcohol ). If yes, what steps has the duty holder undertaken?

Root Cause

• Can the root cause and contributing factors be determined by the Chorus Nominee at the time of ths report - If so state below what you believe these to be.

• Enter root cause(s)

Other Comments

Final Checklist

• Witnesses statement

• Photographs

• Daily site specific prestart

• Daily plant prestart

• Site sketch

Sign off

• Chorus Nominee

  Sign

• Date

  Date