Information
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CAR Title
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Conducted on
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Prepared by
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CAR category
- Injury/Illness
- Damage of Equipment / Property
- Non-conformance/ other
- Safety Breech
- Environmental
- Train Disruption
- Other
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Specify 'other' category meaning
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Date and time of Incident
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Incident Reported by:
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Location address of incident
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Brief description of incident
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If pictures can be taken, please add them in here
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If drawing a diagram helps with explanation of incident, please do here
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What is this incident classified as:
- Injury/Illness
- Damage of Equipment / Property
- Non-conformance/ other
- Safety Breech
- Environmental
- Train Disruption
- Other
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Were there any witnesses present?
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Details of witnesses present. Include Name, Address & Phone.
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Is the person reporting the incident, the same person completing the form?
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Full Name of person completing form
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Add signature
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Contact Phone number of person completing the form
Injury or Illness
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Were there any injuries/illness related to this incident?
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Details of Injured Person
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Full Name
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Gender of Injured or ill person
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Address of Injured or ill person
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Contact Phone number of injured/ill person
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Description of Injury/Illness. Include details of body part/s of the injured/ill person, how it occurred and any other known information.
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Any relevant pictures
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Relevant drawings/diagrams
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Was First Aide given to the injured/ill person?
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Name and contact details of person who PERFORMED the First Aide
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Occupation of The person that PERFORMED the First aide
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Description of First Aide Performed
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As a result of the injury, the person injured was, at some time during the incident: (you must choose 1 or more options)
- unconscious
- taken to hospital
- resuscitated
- fatally injured
- self assessed & fit to return to work
- proceeding to Doctor for Assessment
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Is the injury or illness required by Southbris management to be assessed by a medical practitioner?
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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.
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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.
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Signature of employee/person that was injured/ill where possible
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Explanation as to why there is no signature
Damage of Equipment/Property/Vehicle
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Was there any damaged equipment/property/vehicles related to this CAR?
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Who owns the damaged property/vehicle/equipment ?
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What was damaged?
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Details of damaged Equipment / Property / other
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Was a Southbris Enterprises Pty Ltd vehicle damaged?
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Make and Model of vehicle
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Registration Number of damaged vehicle
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Year of vehicle model if known
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Colour
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Full description of damage to vehicle - include where on vehicle is the damage, extent of damage etc
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Full name of operator/person in charge of the damaged vehicle/property at the time of incident
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Contact details, including Phone and Address of operator/person in charge of the damaged vehicle/property at the time of incident
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Signature of person in charge of damaged vehicle/property/equipment. Signature indicates that all the information in this form is correct.
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Was any other vehicles damaged?
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Who owns the damaged property/vehicle/equipment?
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Make and Model of vehicle
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Registration Number of damaged vehicle
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Year of vehicle model if known
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Colour
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Full description of damage to vehicle - include where on vehicle is the damage, extent of damage etc
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Full name of operator/person in charge of the damaged vehicle/property at the time of incident
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Contact details, including Phone and Address of operator/person in charge of the damaged vehicle/property at the time of incident
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Signature of person in charge of damaged vehicle/property/equipment. Signature indicates that all the information in this form is correct.
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Was any other vehicles damaged?
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Who owns the damaged property/vehicle/equipment?
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Make and Model of vehicle
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Registration Number of damaged vehicle
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Year of vehicle model if known
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Colour
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Full description of damage to vehicle - include where on vehicle is the damage, extent of damage etc
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Full name of operator/person in charge of the damaged vehicle/property at the time of incident
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Contact details, including Phone and Address of operator/person in charge of the damaged vehicle/property at the time of incident
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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)
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Was there an non-conformance related to this CAR?
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Details of the Non Conformance
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Is the non conformance due to an employee of Southbris Enterprises Pty Ltd?
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Employee Full Name
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Employee contact Phone number
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Any further details
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Is the non-conformance due to Environmental issues?
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Detail environmental issues involved in the non-conformance
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Is the non-conformance due to Client request? Eg: work stopped at clients request
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Any known details, please include
Notification to Management
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Notified Gang Administrator or Southbris Enterprises Pty Ltd Supervisor
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Date & Time of notification
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Name of person that notified the GA or Supervisor
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Name of Supervisor or Gang Administrator that was notified
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Name of Supervisor or Gang Administrator that was notified
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Notified Southbris Enterprises Pty Ltd management
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Date & Time of notification
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Name of person that notified Management
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Name of person that notified Management
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Name of person in Southbris Management that was notified
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Name of person in Southbris Management that was notified
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Has Management instructed employee to notify Site Supervisor/Flagman/Protection Officer or any other person of the incident?
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Name of person that instructed the above
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Name of person that notified the above
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Details of person that was notified
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Name of Person that notified The above specified person
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Date & Time of notification
Corrective Action Request 2 Followup - completed by Southbris Enterprises Pty Ltd Management
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Name of Southbris Employee completing this CAR2
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Choose, in which Position of Management the person completing the CAR2 is
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Signature of person completing CAR2
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Date of CAR2 being processed
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Was this CAR regarding an injury/illness?
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Is the employee fit to return to normal duties?
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How was the employee assessed to be "fit for normal duties"?
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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.
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Has management sighted the medical certificate?
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Has the relevant staff been notified of the date that the medical certificate states that the employee is able to return to full duties?
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Details of medical certificate - date fit to return to full duties etc
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Any relevant drawings/diagrams
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Any relevant pictures
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What action has been taken to prevent a reoccurrence of the non conformance, injury/illness/accident or damage that occurred in this CAR1?
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Any relevant pictures
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Any relevant drawings/diagrams
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Was a prestart meeting or other meeting or action required as part of the Followup to prevent a further reoccurrence of the incident?
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Date of specified Prestart Briefing or Meeting or action?
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Any other relevant information to be recorded
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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.
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Sign
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Name of signee (person involved in the reported incident)
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Date
Office Use Only
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Name of Southbris Enterprises Pty Ltd Management that is sighting this CAR1 & CAR2
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Position
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Date of sighting this Followup CAR form
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Does Management require any further action to be taken regarding this incident? If so, please detail
