Visionstream Incident Notification Form

• VS-HS-FRM-005 Issue 6 April 2016

• Please ensure this is emailed to vplseqnz@visionstream.co.nz upon completion

• 1. Notification Owner Details

• Reported Date/Time:

  Date

• Incident Date/Time

  Date

• Reported to (VPL Staff only):

• Project

  UFB

  NGA

  BAU

  M&P

• Reported by:

• Job Title:

• Non Employee Type: (if not VPL - Client/Contractor/Labour Hire/Visitor

• Company Name: (if not VPL)

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?

3. Incident Type/Consequence

• Actual Personal Damage (go to section 4.1)

• Near Miss Personal Damage (go to section 4.1)

• Actual Environmental Damage (go to section 4.2)

• Near Miss Environmental Damage (go to section 4.2)

• Plant/Equipment Damage (go to section 4.3)

• Non SH&E Event - Operational (Refer to SH&E Incident Classifications Criteria)

• Non SH&E Event - Non Operational (Refer to SH&E Incident Classifications Criteria)

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 (Please tick)

• Full-time Casual

• Full time Permanent

• Part time casual

• Part time permanent

• Contractor

• Shift/Start Time (Please tick):

• 0600-1159

• 1200-1559

• 1600-0559

• Roster Arrangement (please tick):

• 1 week roster - 5 days on 2 days off

• 2 week roster - 9 days on 5 days off

• 3 week roster - 14 days on 7 days off

• Other, please specify

• Consequtive Days Worked:

• Average Daily Hours

• 8 hours or less

• 8-10 hours

• 12-14 hours

• 14 hours or more

• 10-12 hours

• Proportion Shift Worked:

• 25% or less

• 26%-50%

• 51%-75%

• 76%-100%

• Overtime

• Workers experience in Task (in months):

• Hours Awake:

• 1-5 hours

• 6-10 hours

• 11-15 hours

• 16-20 hours

• 21 hours or more

• Sleep Opportunities
  Hours of sleep in the last 24 hours

• 1 hour

• 2 hours

• 3 hours

• 4 hours

• 5 hours

• 6 hours

• 7 hours

• 8 hours or more

• Hours of sleep within 24 to 48 hours:

• 1 hour

• 2 hours

• 3 hours

• 4 hours

• 5 hours

• 6 hours

• 7 hours

• 8 hours or more

• Drug and Alcohol Test

  Yes

  No

• Comment

4.2 Environmental Damage Actual or Near Miss

• Environmental Details
  Impact Loss/Type

• RES - Impact on Availability of Resources

• ESC - Erosion and Sediment

• WAS - Waste (Solids, liquids, hazardous and non-hazardous)

• FF - Flora and Fauna

• WAT - Discharges to Surface Waters

• HER - Aboriginal and European Cultural Heritage

• ASS - Acids, Sulphates, Soils

• CON - Contamination to Land and Groundwater

• 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

• Failure

• Damage

• Mobile

• Fixed

• Description of Plant/Equipment:

• Damage Details:

• Estimated Damage Cost

• Level 1 - >$100k

• Level 2 - $10k-$100k

• Level 3 - $1k-$10k

• Level 4 - <$1k

• Type/Model:

• Year:

• Owner Details

• Registration Number:

• Asset Number:

• Notification Form Sign Off

• Select date

  Date

• Name

• Add signature

  Sign