Incident Report - Employee/Witness Statement
KIQ-HSE-009
Personal Information
Name
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Email
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Phone Number
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Work Information
Your position:
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Your Direct Supervisor:
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Roster Duration:
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Day of Roster (eg 4 of 8):
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Shift:
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Please Select
Day
Night
Incident Details
Date Reported:
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Day
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Month
Year
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Reported By:
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Site/Location
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Reported To:
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Position/Company:
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Incident Information
What was your involvement in the incident?
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I was a witness (and was working on the task)
I was a witness (but wasn't working on the task)
I was the supervisor
I was injured
Describe in detail the incident that took place -
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Where was the potential risk identified prior to commencing work?
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Prestart meeting
Take 5, JSEA, or SWMS
Discussions with team members
Permit to Work / Other Permits
It wasn't identified in any of the above
Unknown
What do you think caused the incident?
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Were there any conditions that influenced the incident? E.g. Weather, dust, noise, lighting, congestion etc. How did people influence the incident? What did people do or didn't do? E.g. didn't follow procedure, didn't communicate effectively etc.
How do you think the incident could have been prevented?
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Photo and document upload:
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Any photos you took, any completed risk assessments, diagram of incident location or events.
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Declaration
By signing below you declare that, to the best of your knowledge, the information provided in this statement is a true and accurate reflection of the events that occurred.
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