Incident, Electric Shock and Hazard Report Form
v2.2
Purpose. Workers complete this form to report any injury, electric shock, arc flash, near miss, refrigerant release, fall or hazard so that it can be investigated and reported where required.
1.When to use this form
Use this form for every incident and near miss, including electric shocks with no visible injury, and for hazards you find on a customer site. Phone your supervisor immediately for any electric shock, injury or refrigerant release, then complete the form the same day.
2.Electric shock
For any electric shock record the voltage and supply involved, the path through the body if known, whether the worker lost consciousness or has any burn, and the medical assessment arranged. The worker must not return to work until cleared by a medical practitioner.
3.Describing the event
Describe what happened in order, naming the equipment, circuit or system, the isolation status, the instruments used and any witnesses. Do not speculate about causes; record facts.
4.Supervisor section
The supervisor records the immediate actions, the initial risk rating, whether the event is notifiable to the safety regulator or the electrical regulator, and forwards the form to the Safety, Quality and Business Support Manager within one business day.
5.Privacy
Information on this form is used only to manage the event and meet legal obligations, and is stored in the safety records with restricted access.