J&R Contracting Limited Incident Report

• Audit Title

• Client / Site

• Job Name / Number
  Address

• Conducted on

  Date

• Name of injured Person / Person filling out form

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

• DETAILS OF INJURY?

• PHOTOGRAPHS OF INJURY

  Media

INDICATION OF DAMAGE TO PROPERTY

• WAS THERE ANY DAMAGE TO PROPERTY?

  YES

  NO

• 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

  Yes

  No

  N/A

• RECORD DETAILS AND EXTENT OF DAMAGE

• PHOTOGRAPHS OF DAMAGE

  Media

WITNESSES

• WAS THERE ANY WITNESSES?

  YES

  NO

• RECORD DETAILS OF WITNESSES

OBSERVATIONS (include any contributing factors)

• OBSERVATIONS / WHAT WAS THE CAUSE

  Select Inadequate guarding Inadequate lighting Inadequate/lack of training Inadequate/lack of work procedures Exposure to electricity Use of incorrect tools/equipment Incorrect manual handling equipment 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 Ducts not where plans indicate No spotter Incorrect Markouts Lack of concentration Assumed cable / duct was deeper / shallower

  • Inadequate guarding
  • Inadequate lighting
  • Inadequate/lack of training
  • Inadequate/lack of work procedures
  • Exposure to electricity
  • Use of incorrect tools/equipment
  • Incorrect manual handling equipment
  • 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
  • Ducts not where plans indicate
  • No spotter
  • Incorrect Markouts
  • Lack of concentration
  • Assumed cable / duct was deeper / shallower

• Other Provide Details?

CONCLUSIONS (include any root causes)

• CONCLUSIONS?

RECOMMENDATIONS (include any corrective, preventive actions)

• RECOMMENDATIONS?

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

REPORT COMPLETED BY

• INVESTIGATION COMPLETED BY:

  Sign

• DATE OF INVESTIGATION REPORT

  Date