TPG Incident Report - First Response

• Document No.

• Department

• Report conducted on

  Date

• Prepared by

• TPG Location

  Select

First Incident Details

• Date & Time of Incident

  Date
• Location
  Address

• Incident Priority?

  High

  Medium

  Low

  Trivial

• Incident Type?

  Select Hazard Near-Miss First aid Recordable Injury Illness Fatality Power Truck Incident Property Damage Vehicle Accident

  • Hazard
  • Near-Miss
  • First aid
  • Recordable Injury
  • Illness
  • Fatality
  • Power Truck Incident
  • Property Damage
  • Vehicle Accident

• Please describe type of incident

• Name of on-duty supervisor at time of incident?

• Is immediate medical attention required?

  Yes

  No

• What kind of medical attention was administered?

  Select First Aid Doctor Consulted Hospital Ambulance Medical Attention Declined

  • First Aid
  • Doctor Consulted
  • Hospital
  • Ambulance
  • Medical Attention Declined

Describe What Happened

• Describe what happened. Please be detailed but state only facts.

Record Evidence and Information

• Which of the following do you need to attach to this report to accuractly document this incident?

  Select Evidence Equipment Details Vehicle Details Damages Other Items

  • Evidence
  • Equipment Details
  • Vehicle Details
  • Damages
  • Other Items

Evidence Log

• Please log all relevant evidence below

Evidence

• Type of evidence

  Document

  Photos

  Other

• Photos of evidence (if applicable)

  Media

Vehicle Log

• Please log all relevant vehicle details below

Vehicle

• Vehicle Make

• Vehicle Model

• Vehicle Registration

• Driver (if applicable)

• Photos of equipment (if applicable)

  Media

• Please detail any further information regarding this vehicle (if applicable)

Damage Log

• Please log all relevant damage details below

Damage

• Damage description

• ID number (if applicable)

• Photos of damage (if applicable)

  Media

• Please detail any further information regarding this damage (if applicable)

Other Items Log

• Please log all relevant details of other items below

Item

• Item description

• ID number (if applicable)

• Photos of item (if applicable)

  Media

• Please detail any further information regarding this item (if applicable)

Equipment Log

• Please log all relevant equipment details below

Equipment

• Equipment Make

• Equipment Model

• Equipment ID number (if applicable)

• Photos of equipment (if applicable)

  Media

• Please detail any further information regarding this equipment (if applicable)

Corrective Actions

• Are corrective/further actions required with regard to this incident?

  Yes

  No

• Have all required corrective actions been added as Actions to this inspection?

  Yes

  No

  N/A

• Please add any corrective actions to the appropriate questions above before completing this incident report

Sign Off

• Further action/follow-up/investigation required?

  Yes

  No

• Name of person/people to follow up

• Name of Reporter