Title Page
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Company Engaged By
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Site Name / Address of where incident occured
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Date / Time of incident report completion
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Person completing report
INCIDENT PARTICULARS
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Date & Time of Incident
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Were there any witnesses to this event - if so please include Name and Phone Number
INCIDENT DETAILS
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Type of Incident
- Safety
- Vehicle Incident
- Property Damage
- Environmental
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Main task being performed at time of incident:
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Brief description of incident (what happened):
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What do you think caused or contributed to the incident?
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Photo / Evidence upload as required
CORRECTIVE ACTION
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Contributing Causes - Unsafe Acts and Conditions
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Root Causes - Actions (select all appliable)
- Acts of Violence
- Distraction / Inattention
- Disabled guards, warning systems
- Equipment/materials not secured
- Horseplay
- Incorrect Speed
- Incorrrect loading
- Incorrect lifting
- Incorrect use of equipment/tools
- Incorrect decision making
- Lack of judgement
- Operation of equipment/tools without correct authority
- Overexertion of physical capabilities
- PPE not available
- PPE not used
- Taking shortcuts
- Use of drugs/alcohol
- Use of defective tools/equipment
- Other
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Root Causes - Conditions (select all applicable)
- Acts of nature
- Clutter or debris
- Chemicals
- Defective equipment
- Defective guards/protective devices
- Defective PPE
- Defective warning systems/safety devices
- Defective vehicle
- Defective tools
- Electrical systems
- Height
- Inadequate guards/protective devices
- Inadequate PPE
- Inadequate warning systems/safety devices
- Inadequate/excessive light
- Inadequate workplace layout/design
- Inadequate ventilation
- Inadequate tools/equipment
- Fire/Explosion
- Mechanical
- Noise
- Slippery floors/areas
- Temperature
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Root Causes - Job Factors (select all applicable)
- No training or inadequate training/supervision provided
- Conflicting roles/responsiblities
- Excessive wear and tear
- Inadequate training / knowledge
- Inadequate communication
- Inadequate leadership provided
- Inadequate equipment/tools
- Inadequate repairs/servicing
- Incorrect plans/instruction/references/material provided
- Incorrect storage
- Hazards not identified/assessed/controlled in first instance
- Job placement incorrect
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Hazards contributing to the incident/injury and relevant controls that were in place
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Have there been any concerns around sleep prior to the incident?
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Had any substances been taken prior to the incident that may have been a contributing cause/inflence?
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Have there been any concerns around wellbeing prior to the incident?
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Prevention / Corrective Action - What action has or will be taken to prevent a recurrence?
