Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Operators Details
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Operators Name
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Operators Address
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Operators DOB
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Date Plant Test Passed
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Plant Licence Groups
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Does the Operator have any medical conditions disclosed? Yes/No
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Please enter details here:
Incident Details
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Date of Incident
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Time of Incident
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Location
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Ground Conditions
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Weather Conditions
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Dashcam / CCTV Available Yes/No
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Estimated Speed (mph)
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Was Operator responsible? Yes/No
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Would the Operator be willing to attend court? Yes/No
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Accident Description:
Site Plant Incident Report Form
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Accident Sketch: (add photos of scene)
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If photos taken, please detail how many
Plant Details
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Make of Plant
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Model of Plant
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Plant Number
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Serial Number (if available)
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Hours Run
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Purpose of Journey
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Name of Hire/Lease Company (if applicable)
Description of Damage
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Was there damage to the plant machinery?
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What damage was there to the plant machinery?
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Was there any property damage as a result of the incident?
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What damage was there to property in the incident?
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Are there any injured Parties?
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If Yes, How many Injured Parties?
Name and address of injured party
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Name
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Address
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Details of Injuries
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TKL or Third Party?
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Are there any witnesses?
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Name(s) of Witness(es)
Witness Details
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Name
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Address
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Contact Number
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Declaration: I declare to the best of my knowledge and belief that the details given are true. Information provided within this report will be shared with other parties. For further information please refer to our privacy Policy.
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Signed Operator
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Signed Site Manager
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Date
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Interviewers Details
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Name
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Position
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Date & Time
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Phone Number
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Email Address
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Signature
