TFSNZ Incident Notification Form v1.1

• Client: TFS

• Employee

• Prepared by

• TFS-HS-FRM-005 Issue 6 April 2017

• Please ensure this is emailed to admin@totalfibre.co.nx and Rowan@totalfibre.co.nz upon completion

• Location
  Address

• Conducted on

  Date

1. Notification Owner Details

• Reported Date/Time:

  Date

• Incident Date/Time

  Date

• Reported to (TFS Staff only):

• Project

  UFB

  NGA

  BAU

  M&P

• Reported by:

• Job Title:

• Non Employee Type: (if not TFS/project related - Client/Contractor/Labour Hire/Visitor/Public)

• Company Name: (if not TFS) If public mark as public

2. Notification Details

• Exact Location:

• What happened?

• Potential Consequence/Explain what could have happened?

• Responsible Supervisor:

• Is this a work related incident?

  Yes

  No

• Justification if not work related

• Immediate Actions Taken: (detail of actions, completed by and completion date)

• Were there any other involved persons/witnesses to the incident? Record their details.

3. Incident Type/Consequence

• Incident Type

  Select Actual Personal Damage Near Miss Personal Damage Actual Environmental Damage Near Miss Environmental Damage Plant/Equipment Damage Non SHE Event - Operational Non SHE Event - Non Operational

  • Actual Personal Damage
  • Near Miss Personal Damage
  • Actual Environmental Damage
  • Near Miss Environmental Damage
  • Plant/Equipment Damage
  • Non SHE Event - Operational
  • Non SHE Event - Non Operational

4. Incident Consequence Specific Details

• Name of injured person:

• Department of Injured Person:

• Job Title/Occupation:

• Company Name:

• Summary of Injury/Illness:

• Additional Injury Details:

• Initial Treatment

Shift/Working Hours Details:

• Type of Employment

  Full Time Casual

  Full Time Permanent

  Part Time Casual

  Part Time Permanent

  Contractor

• Shift Start Time

  Date

• Shift duration

• Consecutive Days Worked:

• Average Daily Hours

• Workers experience in Task (in months):

• Hours Awake:

• Sleep Opportunities Hours of sleep in the last 24 hours

• Hours of sleep within 24 to 48 hours:

• Drug and Alcohol Test

  Yes

  No

• Comment

4.2 Environmental Damage Actual or Near Miss

• Environmental Details Impact Loss/Type

  Select RES - Impact on Availability of Resources ESC - Erosion and Sediment Control WAS - Waste (Solid, Liquids, Hazardous and Non Hazardous FF - Fauna and Flora WAT - Discharges to Surface Waters HER - Cultural Heritage ASS - Acids, Sulphates, Soils CON - Contamination to Land and Ground Water DMR - Dirt and Mud on Public Roads NVL - Noise and Vibration

  • RES - Impact on Availability of Resources
  • ESC - Erosion and Sediment Control
  • WAS - Waste (Solid, Liquids, Hazardous and Non Hazardous
  • FF - Fauna and Flora
  • WAT - Discharges to Surface Waters
  • HER - Cultural Heritage
  • ASS - Acids, Sulphates, Soils
  • CON - Contamination to Land and Ground Water
  • DMR - Dirt and Mud on Public Roads
  • NVL - Noise and Vibration

• Details of Environmental Impact:

• Estimated Damage/Repair Cost ($):

• Was this a complaint?

  Yes

  No

4.3 Plant/Equipment Damage or Failure

• Plant Equipment type Damage or Failure

  Select Failure Damage Mobile Fixed

  • Failure
  • Damage
  • Mobile
  • Fixed

• Description of Plant/Equipment:

• Damage Details:

• Estimated Damage Cost

  Level 1 - > $100k

  Level 2 - $10k to $100K

  Level 3 - $1k to $10K

  Level 4 - <$1k

• Type/Model:

• Year:

• Owner Details

• Registration Number:

• Asset Number:

• Notification Form Sign Off

• Select date

  Date

• Name

• Add signature

  Sign