Audit

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

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.