J&R Contracting Limited Incident Report Final

• Audit Title

• Client / Site

• Job Name / Number
  Address

• Conducted on

  Date

• Name of Injured Person/Person filling out form

• Project Manager

• Signature of person filling out form

  Sign

INTRODUCTION

• DATE & TIME OF INCIDENT

  Date
• STREET ADDRESS
  Address

INDICATION OF INJURIES

• WAS THERE ANY INJURIES?

  YES

  NO

• SELECT AREA OF INJURY?

  Select 1) Head 2) Neck 3) Chest 4) Adbomen 5) Shoulder 6) Arms 7) Elbow 8) Forearm 9) Wrist 10) Hand 11) Hip 12) Thigh 13) Knee 14) Calf 15) Top of foot 16) Foot 17) Nape 18) Lumber region 19) Buttock

  • 1) Head
  • 2) Neck
  • 3) Chest
  • 4) Adbomen
  • 5) Shoulder
  • 6) Arms
  • 7) Elbow
  • 8) Forearm
  • 9) Wrist
  • 10) Hand
  • 11) Hip
  • 12) Thigh
  • 13) Knee
  • 14) Calf
  • 15) Top of foot
  • 16) Foot
  • 17) Nape
  • 18) Lumber region
  • 19) Buttock

• PHOTOGRAPHS OF INJURY

  Media

• DETAILS OF INJURY?

INDICATION OF DAMAGE TO PROPERTY

• WAS THERE ANY DAMAGE TO PROPERTY?

  YES

  NO

• Describe how incident happened?

• PHOTOGRAPHS OF DAMAGE

  Media

• SELECT DAMAGE

  Select Comms Gas Power Water Private Property Environmental Vehicle Plant / Machinery Drainage

  • Comms
  • Gas
  • Power
  • Water
  • Private Property
  • Environmental
  • Vehicle
  • Plant / Machinery
  • Drainage

• If Company property, please enter JR Number

WITNESSES

• WAS THERE ANY WITNESSES?

  YES

  NO

• RECORD DETAILS OF WITNESSES

OBSERVATIONS (include any contributing factors)

• OBSERVATIONS / WHAT WAS CAUSE?

  Select Inadequate guarding Inadequate lighting Inadequate/lack of training Inadequate/lack of work procedures Lack of supervision Exposure to chemicals/hazardous substances Exposure to sound/noise Congested Work areas/poor housekeeping Faulty equipment/materials Lack of PPE Fire/Explosion No Risk Assessments No safety equipment Plans not on site or incorrect Ducts not where plans indicate No spotter Incorrect markout Lack of concentration Assumed cable/duct was deeper/shallower

  • Inadequate guarding
  • Inadequate lighting
  • Inadequate/lack of training
  • Inadequate/lack of work procedures
  • Lack of supervision
  • Exposure to chemicals/hazardous substances
  • Exposure to sound/noise
  • Congested Work areas/poor housekeeping
  • Faulty equipment/materials
  • Lack of PPE
  • Fire/Explosion
  • No Risk Assessments
  • No safety equipment
  • Plans not on site or incorrect
  • Ducts not where plans indicate
  • No spotter
  • Incorrect markout
  • Lack of concentration
  • Assumed cable/duct was deeper/shallower

• Other Provide Details?

PROJECT MANAGER TO REVIEW

• SIGNED

  Sign

• DATE OF INVESTIGATION REPORT

  Date

CONCLUSIONS (include any root causes)

• CONCLUSIONS?

FURTHER ACTIONS

• FURTHER ACTIONS

  Select Further training required Discuss at next toolbox meeting Send for repair Have meeting with individual

  • Further training required
  • Discuss at next toolbox meeting
  • Send for repair
  • Have meeting with individual

PHOTOGRAPHS

• PHOTOGRAPHS

  Media

DIRECTOR REVIEWED

• SIGNED

  Sign

• DATE OF INVESTIGATION REPORT

  Date