INTERNAL DAMAGE REPORT NOTICE

• Document No.

• Client / Job Number

• Conducted on

  Date

• Auditor:

• Job Site Address / Location
  Address

Required Information: (Mandatory)

• On-Site Team Leaders Name:

• Operators Name:

• Machine Rego No.

  Select TRON 14 TRON 15 TRON 16 TRON 18 TRON 19 TRON 20 TRON 21 TRON 23 TRON 53 TRON 57 TRON 58 TRON 59

  • TRON 14
  • TRON 15
  • TRON 16
  • TRON 18
  • TRON 19
  • TRON 20
  • TRON 21
  • TRON 23
  • TRON 53
  • TRON 57
  • TRON 58
  • TRON 59

• Truck Drivers Name:

• Truck Rego No.

  Select TRON 25 TRON 26 TRON 27 TRON 35 TRON 36 TRON 37 TRON 38 TRON 45 TRON 47 TRON 49

  • TRON 25
  • TRON 26
  • TRON 27
  • TRON 35
  • TRON 36
  • TRON 37
  • TRON 38
  • TRON 45
  • TRON 47
  • TRON 49

• Name Of Labour (1):

• Name of Labour (2):

• Supervisor in Charge of Crew / Job:

UTILITY DAMAGE:

• Select

  Select APA (Gas) ELECTRICAL - HIGH VOLTAGE ELECTRICAL - LOW VOLTAGE SAPN - COMMS FOXTEL OPTUS TELSTRA WATER (Drinkable) WATER (Recyclable) WATER (Firemain) SEWER DPTI INFRASTRUCTURE PRIVATE PROPERTY IRRIGATION (Private) IRRIGATION (Council) IRRIGATION (School) VEHICLE TOOLS & EQUIPMENT

  • APA (Gas)
  • ELECTRICAL - HIGH VOLTAGE
  • ELECTRICAL - LOW VOLTAGE
  • SAPN - COMMS
  • FOXTEL
  • OPTUS
  • TELSTRA
  • WATER (Drinkable)
  • WATER (Recyclable)
  • WATER (Firemain)
  • SEWER
  • DPTI INFRASTRUCTURE
  • PRIVATE PROPERTY
  • IRRIGATION (Private)
  • IRRIGATION (Council)
  • IRRIGATION (School)
  • VEHICLE
  • TOOLS & EQUIPMENT

• Plans for job correct

  Yes

  No

  N/A

• Was job located?

  Yes

  No

  N/A

• Located by whom:

• Was the Utility / Service physically potholed?

  Yes

  No

  N/A

• Position of Damage

  FOOTPATH

  VERGE

  ROAD

  DRIVEWAY

• What was the cause of damage (how did it occur)

SUPERVISOR'S / MANAGER'S INVESTIGATION DETAILS

• State the specific task / activity at time of incident:

• Was the incident site inspected following the incident?

  Yes

  No

  N/A

CONTRIBUTING FACTORS (Events and conditions that contributed to the incident):

• Was the design, construction or the use of plant / equipment a contributing factor?

  Yes

  No

  N/A

• Was a hazardous condition such as working environment, or the location of tools, equipment or materials, a contributing factor?

  Yes

  No

  N/A

• Was the management system that governed the above task and function defective?

  Yes

  No

  N/A

• Did personal / human factor influence the behaviour / actions of the incident?

  Yes

  No

  N/A

• Was the work method being performed a contributing factor?

  Yes

  No

  N/A

• Was lack of personal protective equipment a contributing factor?

  Yes

  No

  N/A

• Investigated By:

• Date:

  Date

CORRECTIVE ACTION Explain what is required so that the problems that have been identified can be eliminated or effectively controlled.

• 1) Eliminate:

  Yes

  No

  N/A

• 2) Replace / Substitute:

  Yes

  No

  N/A

• 3) Redesign:

  Yes

  No

  N/A

• 4) Administrative controls (i.e. safe operating procedures, PPE):

  Yes

  No

  N/A

• 5) Where required, has a risk assessment been conducted (i.e. plant safety, manual handling)?

  Yes

  No

  N/A

• Person(s) Responsible for completing corrective action:

• Supervisor's Signature:

  Sign

• Date:

  Date

SQE MANAGERS COMMENTS

• Comments:

• Signature:

  Sign

• Date:

  Date