• Date and time of Incident

  • Incident Reported by:

  • Location address of incident
  • Brief description of incident

  • If pictures can be taken, please add them in here

  • If drawing a diagram helps with explanation of incident, please do here

  • What is this incident classified as:

  • Were there any witnesses present?

  • Details of witnesses present. Include Name, Address & Phone.

  • Is the person reporting the incident, the same person completing the form?

  • Full Name of person completing form

  • Add signature

  • Contact Phone number of person completing the form

Injury or Illness

  • Were there any injuries/illness related to this incident?

  • Details of Injured Person

  • Full Name

  • Gender of Injured or ill person

  • Address of Injured or ill person
  • Contact Phone number of injured/ill person

  • Description of Injury/Illness. Include details of body part/s of the injured/ill person, how it occurred and any other known information.

  • Any relevant pictures

  • Relevant drawings/diagrams

  • Was First Aide given to the injured/ill person?

  • Name and contact details of person who PERFORMED the First Aide

  • Occupation of The person that PERFORMED the First aide

  • Description of First Aide Performed

  • As a result of the injury, the person injured was, at some time during the incident: (you must choose 1 or more options)

  • Is the injury or illness required by Southbris management to be assessed by a medical practitioner?

  • Ensure Medical Certificate is obtained to show clearance to return to full duties. Medical certificates will be filed in the injured/ill employee/s file.

  • Signature of employee/person that was injured/ill. Signature indicates that all the information in this form is correct, and that he/she has had or is in the process of obtaining a clearance from a medical practitioner to return to normal duties if applicable. The above mentioned employee of Southbris Enterprises Pty Ltd is satisfied that no further action is required by her/himself, Southbris Enterprises Pty Ltd or any affiliated contract/client in relation to this incident, now or in the future.

  • Signature of employee/person that was injured/ill where possible

  • Explanation as to why there is no signature

Damage of Equipment/Property/Vehicle

  • Was there any damaged equipment/property/vehicles related to this CAR?

  • Who owns the damaged property/vehicle/equipment ?

  • What was damaged?

  • Details of damaged Equipment / Property / other

  • Was a Southbris Enterprises Pty Ltd vehicle damaged?

  • Make and Model of vehicle

  • Registration Number of damaged vehicle

  • Year of vehicle model if known

  • Colour

  • Full description of damage to vehicle - include where on vehicle is the damage, extent of damage etc

  • Full name of operator/person in charge of the damaged vehicle/property at the time of incident

  • Contact details, including Phone and Address of operator/person in charge of the damaged vehicle/property at the time of incident

  • Signature of person in charge of damaged vehicle/property/equipment. Signature indicates that all the information in this form is correct.

  • Was any other vehicles damaged?

  • Who owns the damaged property/vehicle/equipment?

  • Make and Model of vehicle

  • Registration Number of damaged vehicle

  • Year of vehicle model if known

  • Colour

  • Full description of damage to vehicle - include where on vehicle is the damage, extent of damage etc

  • Full name of operator/person in charge of the damaged vehicle/property at the time of incident

  • Contact details, including Phone and Address of operator/person in charge of the damaged vehicle/property at the time of incident

  • Signature of person in charge of damaged vehicle/property/equipment. Signature indicates that all the information in this form is correct.

  • Was any other vehicles damaged?

  • Who owns the damaged property/vehicle/equipment?

  • Make and Model of vehicle

  • Registration Number of damaged vehicle

  • Year of vehicle model if known

  • Colour

  • Full description of damage to vehicle - include where on vehicle is the damage, extent of damage etc

  • Full name of operator/person in charge of the damaged vehicle/property at the time of incident

  • Contact details, including Phone and Address of operator/person in charge of the damaged vehicle/property at the time of incident

  • Signature of person in charge of damaged vehicle/property/equipment. Signature indicates that all the information in this form is correct.

Non Conformance - (when a task cannot be completed)

  • Was there an non-conformance related to this CAR?

  • Details of the Non Conformance

  • Is the non conformance due to an employee of Southbris Enterprises Pty Ltd?

  • Employee Full Name

  • Employee contact Phone number

  • Any further details

  • Is the non-conformance due to Environmental issues?

  • Detail environmental issues involved in the non-conformance

  • Is the non-conformance due to Client request? Eg: work stopped at clients request

  • Any known details, please include

Notification to Management

  • Notified Gang Administrator or Southbris Enterprises Pty Ltd Supervisor

  • Date & Time of notification

  • Name of person that notified the GA or Supervisor

  • Name of Supervisor or Gang Administrator that was notified

  • Name of Supervisor or Gang Administrator that was notified

  • Notified Southbris Enterprises Pty Ltd management

  • Date & Time of notification

  • Name of person that notified Management

  • Name of person that notified Management

  • Name of person in Southbris Management that was notified

  • Name of person in Southbris Management that was notified

  • Has Management instructed employee to notify Site Supervisor/Flagman/Protection Officer or any other person of the incident?

  • Name of person that instructed the above

  • Name of person that notified the above

  • Details of person that was notified

  • Name of Person that notified The above specified person

  • Date & Time of notification

Corrective Action Request 2 Followup - completed by Southbris Enterprises Pty Ltd Management

  • Name of Southbris Employee completing this CAR2

  • Choose, in which Position of Management the person completing the CAR2 is

  • Signature of person completing CAR2

  • Date of CAR2 being processed

  • Was this CAR regarding an injury/illness?

  • Is the employee fit to return to normal duties?

  • How was the employee assessed to be "fit for normal duties"?

  • If a medical practitioner was seen for the reported injury/illness, a medical certificate for clearance to work and fit for full duties certificate MUST be obtained to be permitted to return to work.

  • Has management sighted the medical certificate?

  • Has the relevant staff been notified of the date that the medical certificate states that the employee is able to return to full duties?

  • Details of medical certificate - date fit to return to full duties etc

  • Any relevant drawings/diagrams

  • Any relevant pictures

  • What action has been taken to prevent a reoccurrence of the non conformance, injury/illness/accident or damage that occurred in this CAR1?

  • Any relevant pictures

  • Any relevant drawings/diagrams

  • Was a prestart meeting or other meeting or action required as part of the Followup to prevent a further reoccurrence of the incident?

  • Date of specified Prestart Briefing or Meeting or action?

  • Any other relevant information to be recorded

  • The above mentioned states that he/she has had clearance from a medical practitioner to continue work, if applicable and has provided a certificate if such. Where the above mentioned does not receive a medical certificate clearance to work, he/she is hereby stating by signing here that they are 100%fit to return to full duties. The above mentioned is satisfied that no further action is required by him/herself, Southbris Enterprises Pty Ltd or any affiliated contractor/client, in relation to this incident, now or in the future.

  • Sign

  • Name of signee (person involved in the reported incident)

  • Date

Office Use Only

  • Name of Southbris Enterprises Pty Ltd Management that is sighting this CAR1 & CAR2

  • Position

  • Date of sighting this Followup CAR form

  • Does Management require any further action to be taken regarding this incident? If so, please detail

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