RTIO Incident Report

• Incident Title

• Client / Site

• Conducted on

  Date

• Prepared by

Incident Time & Location

• Date and time of incident

  Date

• Date and time incident was reported to RTIO Supervisor

  Date

• Location Description

• Accountable Organisation Unit

Incident Description

• Photos

  Media

• Drawings

  Drawing

• Was it a near miss / hit

  Yes

  No

  N/A

• Impacts

  Select Health Safety Environment Community Quality Security Process

  • Health
  • Safety
  • Environment
  • Community
  • Quality
  • Security
  • Process

• Your impression of the risk

  Low

  Moderate

  High

  Critical

• Short Description

• Long Description

• Ideas to prevent future incidents

• Corrective Action to make area Safe

Persons Involved 1

• Name

• SAP Number

• Job Title:

• Witness Statement

• Witness Statement Signature

  Sign

• Phone:

• Employee or Contractor

  Employee

  Contractor

• Sent for AOD

  Yes

  No

  N/A

• AOD Date

  Date

• AOD Result

  Negative

  Non Negative

• Role Code

  Select Complainant Contractor Principal Community Member RTIO Company Rep Eye Witness First Aider Injured / ill Person Investigator Team Member Lead Investigator Incident Reporter Stakeholder Supervisor / Shift Leader Uninjured Involved Person

  • Complainant
  • Contractor Principal
  • Community Member
  • RTIO Company Rep
  • Eye Witness
  • First Aider
  • Injured / ill Person
  • Investigator Team Member
  • Lead Investigator
  • Incident Reporter
  • Stakeholder
  • Supervisor / Shift Leader
  • Uninjured Involved Person

• Describe injury.

• Detail any first-aid or medical treatment administered. (Provide names)

• First Aid Received

  Date

Persons Involved 2

• Name

• SAP Number

• Job Title:

• Witness Statement

• Witness Statement Signature

  Sign

• Phone:

• Employee or Contractor

  Employee

  Contractor

• Sent for AOD

  Yes

  No

  N/A

• AOD Date

  Date

• AOD Result

  Negative

  Non Negative

• Role Code

  Select Complainant Contractor Principal Community Member RTIO Company Rep Eye Witness First Aider Injured / ill Person Investigator Team Member Lead Investigator Incident Reporter Stakeholder Supervisor / Shift Leader Uninjured Involved Person

  • Complainant
  • Contractor Principal
  • Community Member
  • RTIO Company Rep
  • Eye Witness
  • First Aider
  • Injured / ill Person
  • Investigator Team Member
  • Lead Investigator
  • Incident Reporter
  • Stakeholder
  • Supervisor / Shift Leader
  • Uninjured Involved Person

• Describe injury.

• Detail any first-aid or medical treatment administered. (Provide names)

• First Aid Received

  Date

Persons Involved 3

• Name

• SAP Number

• Job Title:

• Witness Statement

• Witness Statement Signature

  Sign

• Phone:

• Employee or Contractor

  Employee

  Contractor

• Sent for AOD

  Yes

  No

  N/A

• AOD Date

  Date

• AOD Result

  Negative

  Non Negative

• Role Code

  Select Complainant Contractor Principal Community Member RTIO Company Rep Eye Witness First Aider Injured / ill Person Investigator Team Member Lead Investigator Incident Reporter Stakeholder Supervisor / Shift Leader Uninjured Involved Person

  • Complainant
  • Contractor Principal
  • Community Member
  • RTIO Company Rep
  • Eye Witness
  • First Aider
  • Injured / ill Person
  • Investigator Team Member
  • Lead Investigator
  • Incident Reporter
  • Stakeholder
  • Supervisor / Shift Leader
  • Uninjured Involved Person

• Describe injury.

• Detail any first-aid or medical treatment administered. (Provide names)

• First Aid Received

  Date

Persons Involved 4

• Name

• SAP Number

• Job Title:

• Witness Statement

• Witness Statement Signature

  Sign

• Phone:

• Employee or Contractor

  Employee

  Contractor

• Sent for AOD

  Yes

  No

  N/A

• AOD Date

  Date

• AOD Result

  Negative

  Non Negative

• Role Code

  Select Complainant Contractor Principal Community Member RTIO Company Rep Eye Witness First Aider Injured / ill Person Investigator Team Member Lead Investigator Incident Reporter Stakeholder Supervisor / Shift Leader Uninjured Involved Person

  • Complainant
  • Contractor Principal
  • Community Member
  • RTIO Company Rep
  • Eye Witness
  • First Aider
  • Injured / ill Person
  • Investigator Team Member
  • Lead Investigator
  • Incident Reporter
  • Stakeholder
  • Supervisor / Shift Leader
  • Uninjured Involved Person

• Describe injury.

• Detail any first-aid or medical treatment administered. (Provide names)

• First Aid Received

  Date

Persons Involved 5

• Name

• SAP Number

• Job Title:

• Witness Statement

• Witness Statement Signature

  Sign

• Phone:

• Employee or Contractor

  Employee

  Contractor

• Sent for AOD

  Yes

  No

  N/A

• AOD Date

  Date

• AOD Result

  Negative

  Non Negative

• Role Code

  Select Complainant Contractor Principal Community Member RTIO Company Rep Eye Witness First Aider Injured / ill Person Investigator Team Member Lead Investigator Incident Reporter Stakeholder Supervisor / Shift Leader Uninjured Involved Person

  • Complainant
  • Contractor Principal
  • Community Member
  • RTIO Company Rep
  • Eye Witness
  • First Aider
  • Injured / ill Person
  • Investigator Team Member
  • Lead Investigator
  • Incident Reporter
  • Stakeholder
  • Supervisor / Shift Leader
  • Uninjured Involved Person

• Describe injury.

• Detail any first-aid or medical treatment administered. (Provide names)

• First Aid Received

  Date

Persons Involved 6

• Name

• SAP Number

• Job Title:

• Witness Statement

• Witness Statement Signature

  Sign

• Phone:

• Employee or Contractor

  Employee

  Contractor

• Sent for AOD

  Yes

  No

  N/A

• AOD Date

  Date

• AOD Result

  Negative

  Non Negative

• Role Code

  Select Complainant Contractor Principal Community Member RTIO Company Rep Eye Witness First Aider Injured / ill Person Investigator Team Member Lead Investigator Incident Reporter Stakeholder Supervisor / Shift Leader Uninjured Involved Person

  • Complainant
  • Contractor Principal
  • Community Member
  • RTIO Company Rep
  • Eye Witness
  • First Aider
  • Injured / ill Person
  • Investigator Team Member
  • Lead Investigator
  • Incident Reporter
  • Stakeholder
  • Supervisor / Shift Leader
  • Uninjured Involved Person

• Describe injury.

• Detail any first-aid or medical treatment administered. (Provide names)

• First Aid Received

  Date