About this Form:This form is to be completed when a Hazard, Incident, Injury or Near Miss has been identified or occurs. This information assists us in identifying OH&S related issues on site and to take immediate action to reduce risk or hazards on site. This form is to be completed by an on-hired worker, employee or host employer supervisor or any person who identifies an accident or injury occuring. Please ensure you call Lloyd Philips Group to verbally convey initial details of risks on site immediately by calling 1300 138 689.
Details of Person completing this form:
Name
Address
Suburb Post Code
Phone Number
Mobile
Host Employer details and location of where Hazard/Incident/Acccident took place:
Employer/Company
Site Name
Site Address
Suburb
Supervisor Name
Date
Date of Incident
Time of Incident AM PM
Description of Hazard/Incident/Acccident:
Recommend any Action you feel should be taken or was taken at the time:
Has Host Employer representative been notified? Yes No
Position
Has Person who reported this issue been given feedback? Yes No
Action taken after being notified:
Additional Notes:
LLoyd Philips