Whsmp · OPW16/0021

                                                                                              Incident/Injury /Hazard Report Form
                                                                                                                                          HB-HSEQ-F-027-B
                                                                                                                                               Version: 11


 Is a Formal CAR (HB-HSEQ-F-029-A) required and has it been provided to the relevant party/ies?                                        Yes          No
     HB Foreman:                                                                      HB P/Manager:


                     State Authority Notified:            Yes        No               Report Status:       Notified        Interim     Finalised

                   Full investigation required:           Yes        No

 CRITICAL / SERIOUS INCIDENTS
 Is a Critical Incident Checklist (HB-HSEQ-F-027-D) Required? – Yes                   - N/A
 Person/s who may have been involved or exposed to this incident been offered counselling via Hutchins Builders Employee Assistance Program –
 Yes - N/A
  WHERE PERSON/S HAS ACCEPTED COUNSELLING?                                      YES      REHABILITATION SERVICES                                   YES
  Has Hutchinson Senior Management been Contacted to initiate                            Person/s covered under an employer workers
  EAP                                                                                    compensation scheme
                                                                                         Person/s covered under a personal accident insurance
  Has person/s Employer been contacted
                                                                                         policy scheme

  REVIEW OF INCIDENT
  A review of the incident has been carried out to              Person/s conducting review:
  ensure procedures are effective - Yes

                                                                Project Manager           Site Manager        HS Officer/Advisor
 Ensure copies of the following documents are attached.
  SIGNED COPIES OF:                  Head Contract                              Subcontract                           Scope of Works

  RELEVANT DOCUMENTS ATTACHED                                             Yes    RELEVANT DOCUMENTS ATTACHED                                         Yes
  Induction Records                                                              Investigation Reports
  SWMS/JSEA/SOPs                                                                 Photos
  Subcontract Agreement                                                          Plans / drawings
  Subcontractor Certificate of Currency                                          Permits
  Previous/Current Corrective Actions                                            Regulator Report
  Toolbox Talks/Prestart Meetings                                                Other Documents:

 ADDITIONAL COMMENTS:




  Person who filled out form.                                                   Site Manager Name.




  Print Name:                                                                   Print Name:


  Sign Name:                                      Date:                         Sign Name:                                   Date:


Notification of all incidents (except minor first aid) are to be reported to the Project
Manager, Team Leader Or Team Safety Manager IMMEDIATELY after the event, via
                                    phone or email.
                   The Corporate HSE Manager SHALL be notified within 24 hours
                              ALL QUESTIONS MUST BE COMPLETED
 ALL fields are to be completed prior to closing out the incident.                                                                           Page 3 of 3