Mirait Technologies Australia - Incident Report

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

Section 1: General Information

• Date/Time of Incident

  Date

• Date of Report

  Date

• Exact Location of Incident

• Employee Involved

• Activity of Employee

• Witness Name/ Contact Details

Section 2: Type of Incident

• Sections to be completed:
  Lost Time Incident Sections 1, 2, 3, 7, 8, 9
  Minor Injury Sections 1, 2, 3, 7, 8, 9
  Near Miss Sections 1, 2, 7, 8, 9
  Damage Sections 1, 2, 7, 8, 9
  Vehicle Sections 1, 2, 4, 7, 8, 9
  Security Sections 1, 2, 5, 7, 8, 9
  Environmental Sections 1, 2, 6, 7, 8, 9
  

• Type of Incident

  Select Lost Time Incident Minor Injury Near Miss Damage Vehicle Security Environmental

  • Lost Time Incident
  • Minor Injury
  • Near Miss
  • Damage
  • Vehicle
  • Security
  • Environmental

Section 3: Lost Time, Minor Injury

• Nature of Injury e.g. Abrasion, Break, Burns, Damage, Exposure, Lacerations, Needle Stick, Soft Tissue, Sting, Strain

• Body Part e.g. Arm, Leg, Head etc.

• Medical Attention Required

  Yes

  No

  N/A

Section 4: Vehicle

• Registration Number

• Licence Number of MTA Driver

• Police Report - Report Number

  Yes

  No

  N/A

• 2nd Vehicle Drivers Name, Contact Details, Drivers Licence, Registration Number

Section 5: Security

• Item Stolen, Damage etc.

• Police Report - Report No.

  Yes

  No

  N/A

Section 6: Environmental

• Category of Incident

  Select Chemical Spill Noise Dust Air Water Contamination Heritage Flora/Fauna Other

  • Chemical Spill
  • Noise
  • Dust
  • Air
  • Water Contamination
  • Heritage
  • Flora/Fauna
  • Other

• DECC/EPA Notified - Report No.

  Yes

  No

  N/A

• Other Authorities Notified e.g. Council, Energy, Water - Agency Notified

  Yes

  No

  N/A

• Immediate Controls Used To Contain Incident - Type of Control

  Yes

  No

  N/A

Section 7: Description of Incident

• Diagram if required:

  Drawing

Section 8: Incident Investigation

• To be completed by Project Manager and/or WHSE Manager
  Consider root causes such as procedural, training, equipment.

Section 9: Corrective & Preventative Actions

• Include any modifications to Plant, training, & work instructions etc.

• Other Comments

Photos

• Photos

  Media

Details Manger/Supervisor

• Name of Manager/Supervisor

  Sign

• Date

  Date

Incident reviewed by WHSE Co-ordinator & tabled for action in company meetings

• Name of Manager/Supervisor/WHSE Representative

  Sign

• Date

  Date

Office Use Only

• Received Date

  Date

• Action Required:

  Yes

  No

  N/A

• Received by:

• Incident No.