Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
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Not sure? - Help Attached!
Details of person who had the accident
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Name of the person who had the accident
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Occupation of the person who had the accident
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Employed Worker
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Cascade Employee Number
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Agency Worker
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Agency Name
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Not sure? - Help Attached!
Details of person taking this report
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Name of the person filling out this report
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Occupation of the person taking this report
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Not sure? - Help Attached!
Details of the accident - when and where
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Date and time of the accident
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Location of Accident
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Did the Emergency services attend location
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Which Emergency service attended?
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Not sure? - Help Attached!
About the accident
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Vehicle Registration/ Trailer Number/ FLT Serial Number
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Category of Incident
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Has this been reported to the Insurance
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Why Not?
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Explain what happened, also describe if known the cause of the accident
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Any injured parties
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Who
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Not sure? - Help Attached!
For the employer only to complete this section
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Did the Accident result in a fatality
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Major Incident Response Procedure Must be Implemented
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Has the Accident information been entered onto the KPI Vehicle accident sheet on the day of the Incident.
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Was the Accident investigated within 24 hours
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Why Not
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Have this accident been reported to the site management?
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Not sure? - Help Attached!
Signatures
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Signature of person making the report
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Signature of the person who had the accident
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Not sure? - Help Attached!
