SlideShare a Scribd company logo

Form 006 - Incident Report Form

•
•
Flevy.com Best Practices
Flevy.com Best Practices

The incident report form collects information about incidents that occur at a company's industrial sites. It requests details about the date, time, location and type of incident, as well as estimates of any costs. The form also determines the appropriate authorities to notify depending on the classification of the incident. The report documents a description of the incident and controllable factors. Finally, it outlines short-term and long-term actions to prevent future occurrences and requires approval signatures.

Related slideshows

Ficha de saude
Ficha de saudeFicha de saude
Ficha de saude
 
Modelo de declaração de vínculo empregatício
Modelo de declaração de vínculo empregatícioModelo de declaração de vínculo empregatício
Modelo de declaração de vínculo empregatício
 
Ficha cadastro de aluno
Ficha cadastro de alunoFicha cadastro de aluno
Ficha cadastro de aluno
 
1 of 2
Form 006 Incident Report Form Rev 00 (Insert Co. Name) INCIDENT NO. Industry Building Date of Incident: Time of Incident: Incident reported to: Civil / (am Mining / /pm Incident is related to: ) Industrial Safety and Health Environmental Other, specify Location of Incident: Name of Foreman / Supervisor: Report and Investigation By: Date: Type of Incident (More than one may have to be ticked) Potential Damage (near miss) Plant /Property/Product Damage Fatality Serious bodily harm / / Environmental Damage Work caused Illness Describe the Damage Estimated Cost: Class of Incident Potential Class 1 (Near Miss) Notify Statutory Authorities (as appropriate) Division of Workplace Health & Safety (DWHS) Electrical Safety Office (ESO) Department of Natural Resources and Mining (DNRM) Class 2 Yes Yes Yes No No No Description of incident: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ (Insert Co. Name) Form 006 Incident Report Form Rev 00 Page 1 of 4
(Insert Co. Name) STEP 3(b) Form 006 Incident Report REVIEW SELECTED CONTROLLABLE FACTORS FOR EFFECTIVENESS Review the factors above. Does the list of factors meet the VAACS criteria? Yes □ No □ Viable practical and does not create a new & unacceptable level of risk Achievable - achievable within the constraints of capital/cash flow/business viability Acceptable - accepted/owned by the end users Compatible - compatible with risk being managed Sustainable STEP 4 - - sustainable over time for medium and high risk situations STATE THE ACTION TO BE TAKEN TO PREVENT THE INCIDENT/ACCIDENT HAPPENING AGAIN Short Term Action Person Responsible for Action Planned Completion Date Long Term Action Person Responsible for Action Planned Completion Date (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) Remedial Action Approved By Name & Signature: Date: Project Manager’s Signature (Insert Co. Name) Form 006 Incident Report Form Rev 00 Page 3 of 4

More Related Content

Form 006 - Incident Report Form

  • 1. Form 006 Incident Report Form Rev 00 (Insert Co. Name) INCIDENT NO. Industry Building Date of Incident: Time of Incident: Incident reported to: Civil / (am Mining / /pm Incident is related to: ) Industrial Safety and Health Environmental Other, specify Location of Incident: Name of Foreman / Supervisor: Report and Investigation By: Date: Type of Incident (More than one may have to be ticked) Potential Damage (near miss) Plant /Property/Product Damage Fatality Serious bodily harm / / Environmental Damage Work caused Illness Describe the Damage Estimated Cost: Class of Incident Potential Class 1 (Near Miss) Notify Statutory Authorities (as appropriate) Division of Workplace Health & Safety (DWHS) Electrical Safety Office (ESO) Department of Natural Resources and Mining (DNRM) Class 2 Yes Yes Yes No No No Description of incident: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ (Insert Co. Name) Form 006 Incident Report Form Rev 00 Page 1 of 4
  • 2. (Insert Co. Name) STEP 3(b) Form 006 Incident Report REVIEW SELECTED CONTROLLABLE FACTORS FOR EFFECTIVENESS Review the factors above. Does the list of factors meet the VAACS criteria? Yes □ No □ Viable practical and does not create a new & unacceptable level of risk Achievable - achievable within the constraints of capital/cash flow/business viability Acceptable - accepted/owned by the end users Compatible - compatible with risk being managed Sustainable STEP 4 - - sustainable over time for medium and high risk situations STATE THE ACTION TO BE TAKEN TO PREVENT THE INCIDENT/ACCIDENT HAPPENING AGAIN Short Term Action Person Responsible for Action Planned Completion Date Long Term Action Person Responsible for Action Planned Completion Date (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) Remedial Action Approved By Name & Signature: Date: Project Manager’s Signature (Insert Co. Name) Form 006 Incident Report Form Rev 00 Page 3 of 4