HOW TO FILL OUT THIS FORM: (This form is for ALL hazards, incidents and accidents)
Note: This is not a WorkCover claim form
Person involved in incident or accident
- Fill in Sections A to C and sign form
- Copy form and retain copy as a receipt of injury notification
- Pass form on to your supervisor or safety officer and participate in investigation of the incident with the safety officer and health & safety representative
- Visitor Pass form on to the supervisor or the safety officer of the area, OHSE or to Security & Traffic
- Supervisor or person providing initial treatment should fill in the form if the injured person is unable to do so
NOTE: Reports containing confidential issues can be forwarded directly to OHSE, bypassing any party as necessary.
Person reporting environmental incident, hazard, fire or property damage
- Fill in Sections A and sign form
- Pass form on to your supervisor or safety or environmental officer, as appropriate
- Visitor: Pass form on to site supervisor / manager
Supervisor
- Notify safety or environmental officer immediately. If not available, notify health & safety representative
- Review form and participate in investigation of the hazard or incident with the safety or environmental officer and health & safety representative
- Complete Section D and E and sign form
- Forward form to safety or environmental officer, as appropriate
Health & Safety Representative
- Participate in investigation of reported hazard or incident
- Sign form after completion of Section G, H and I
- Forward form to safety or environmental officer, as appropriate
Management
- Review form, sign and indicate the status of recommendations section J
- Retain copy of completed form for records
- Forward completed form to safety or environmental officer for distribution
Occupational Health, Safety & Environment (OHSE)
- Report appropriate incidents to relevant regulatory authorities
- Review status of preventive actions
A. Person Completing the form:
Full Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Occurrence Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
B. Description of Incident/Hazard {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
C. Incident / Hazard Details
Date of Incident/Hazard/Accident {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Time of Incident {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Date Reported {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Time Reported {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Reported to {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Location of Incident/Hazard/Accident {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Period Incident Occured {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Shift Commenced at (Time) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Description of injuries/illness {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Photo's of the Incident {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Vehicle Details
Vehicle {binding ItemNumber}
Name of Insured {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Policy Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Your Vehicle Registration? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Make & Model {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Body Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Details of Damage to Company Vehicle {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Was the Vehicle Towed from the Scene of the Accident? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
(If Yes) Who Towed the Vehicle? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Contact Number of Tower {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Cost of Towing? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Journey Details
State what vehicle(s) was carrying {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Point of Departure {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Anticipated Destination for the Trip {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Third Party Driver Details
Third Party Driver {binding ItemNumber}
Third Party Full Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Mobile {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Third Party Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Details of Third Party Damage {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Third Party Registration No {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Make & Model {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Body Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Name of other party's Insurer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Insurance Policy Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
D. Employer Details
Employer State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Employer Company {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Employer Sector/Site {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Customer Site? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Agents Site Name? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Employer Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
E. Person Involved Details
Person Involved Full Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Person Involved Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Person Involved Occupation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Person Involved Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Person Involved Job Title {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Person Involved Employment Classification {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Person Involved Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Driver's License No {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Driver's License Expiry {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
F. Witness Details
Witness Full Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Witness Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Witness Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Investigation Steps
G. Immediate Action Taken to Prevent a Recurrence {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
H. Action Taken By {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Position {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Details of Investigation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
J. Recommendations: (Management) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Manager's Full Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Manager's Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Incident/Accident Report Acknowledgment
Entered By Person - Person Involved to sign if completing form - otherwise by person completing this form.
Entered By: Full Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Entered By Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Entered By Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Notice Acknowledged on Behalf of the Company (Designated manager to Sign)
Manager's Full Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Manager's Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Manager Signed Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}