Incident

INCIDENT REPORT FORM Number

PART A – INITIAL REPORTING

A1 – Type of Incident
To be completed by the Originator and Line Supervisor
Indicate the applicable classifications in order of relevance

Complete Parts A and C Only Complete Parts A, B and C Complete Part A2 Only

Regulatory Near Miss/ Personal Injury/ Unplanned Property/Equipment Security/Theft/

Report HSE-MS Non- Illness Environmental Damage or Loss Other
Required conformance (For non work-related, Release
only complete A2 & B1)

A2 – Incident Details
To be completed by the Originator and Line Supervisor

Date and Time of Incident: / / : 24

Date and Time of Incident: / / : 24 Hrs
Hrs DD MM YY
DD MM YY

Location (Facility/Site name): Person Reporting:

Supervisor Name: Supervisor Title:
Location on Facility/Site:

Activity at Time of Incident:

Description: (Describe the incident)

What action was performed to make location/area safe?:

Name/s of Witness/es:

A3 – Consequence or Impact of Incident

To be completed by the Line Supervisor in consultation with the site HSE Advisor/ Responsible Manager.
Severity Ratings are not exhaustive and are for guidance only. If classifications are not relevant, judgement must be used to describe the appropriate ratings.

(Please tick one for each Severity Rating) LEVEL 1 – MINOR LEVEL 2 – MODERATE LEVEL 3 – MAJOR LEVEL 4 - CRITICAL
First Aid/Minor Injury.
Permanent Disability
PERSONAL INJURY/ILLNESS Near Miss or Hazard MTI or ADI 1 or more fatalities
Injury, LTI
with no serious effects
LOSS OF PRODUCTION <1 hour >1 hour to <1 day >1 day to <1 week >1 week
PROPERTY/EQUIP’T. DAMAGE/LOSS <US$10,000 US$10,000 to US$20,000 US$20,000 to US$40,000 >US$40,000
ENVIRONMENTAL SPILL/RELEASE <80 litres >80 litres to <1,000 litres >1,000 litres to <1 million >1 million litres

Actual Severity:
What was the ‘actual’ outcome of the event?

Potential Severity:
Ask yourself WHAT realistically is the worst
outcome that could have occurred.

Eftech Responsible Manager to Review and Sign-off, prior to forwarding to HSE Department, Perth.

Name: Signature: Date: / /

DD MM YY

T.I. #4895-2