Sandvik Hazard / Incident / Concern Card

• Incident No:

• Name (Optional):

• Date of Incident / Concern:

  Date
• Location of Incident / Concern:
  Address

• Supervisor Name:

• Short Description:

Complete the appropriate sections:

• Injured Person:

• Part of Body:

• First Aider:

• Injury Type:

• Treatment Provided:

• Equipment Damage:

• Contaminant Spilled:

• Volume:

Immediate Action Taking

Supervisor to Complete:

• Actual Incident Classification:

  Select 1 = Minor 2 = MTI 3 = RWI 4 = LTI 5 = Fatality

  • 1 = Minor
  • 2 = MTI
  • 3 = RWI
  • 4 = LTI
  • 5 = Fatality

• Potential Clasification:

  Select Low Medium High Extreme

  • Low
  • Medium
  • High
  • Extreme

An investigation is required for all incidents of 2 or above as well as those with a potential classification of high or extreme, as outlined in SSP-09

• Has action been completed?

  Select Yes No

  • Yes
  • No

• Close this issue out?

  Select Yes No

  • Yes
  • No

Supervisor to ensure that this information is entered into Sandvik Cintellate incident database and supply feedback of corrective actions to initiator within 14 days.