Title Page
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Type of Incident
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Report Number
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Date Raised
Details
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Date of Incident
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Time of Incident
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Location
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Department
Full Details of the Incident
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Record as much detail as possible , including the name of any substance involved. The type of machinery in use, any damage to property, the events that led up to the incident and the part played by other people. If you have any documents or pictures, they can be uploaded below
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Details
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Media
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Witness name
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Date
Proposed Corrective/Preventive Actions
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To be completed by the section Team leader/ Manager following the investigation
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Immediate causes ( what unsafe acts or conditions caused the incident)
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Agreed action measures
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Time Lost
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Investigator
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Other
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Proposed Completion Date
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Action to be carried out by
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Agreed by
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Signature
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Date
HSEQ Audit of Corrective/ Preventative actions
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Is a post incident risk assessment / SOP required?
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Have the necessary corrective/preventative measures been completed and proved effective?
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If no , Give details
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Audit by
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Signature
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Date
Director Review of Corrective/Preventive Actions
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Have the necessary Corrective/Preventive measures been completed and proved effective?
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If No, Give Details
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Audit by
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Signature
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Date
