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Critical Incident & ICAM Investigation Advice
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Incident Location
*
Date / Time of Incident
*
Date
Time
Was Anyone Injured?
*
Yes - Single Injury Incident
Yes - Multiple Injury Incident
No
Name of Injured Person
*
First
Last
Names of Injured Persons
Initial Injury Classification
Near miss
First aid
Medical treatment / Alternate work
Lost time
Fatality
Was Property Damaged?
Yes
No
Assets Involved
Estimated Cost Impact: $
Did the incident cause Environmental Harm?
No
Yes - Release of pollutants to sensitive area
Yes- Major release of pollutants
Yes- Large Scale irreversible harm
Yes- Licence or Permit Breach
Other
If Other
Is there likely to be impact to Corporate Reputation?
No
Yes - Attention from media, concern by local community
Yes - Significant media, public, regulatory attention
Yes -Significant public interest or regulator intervention could occur or potentially could occur
Other
If Other
Brief description of incident
*
Photo Upload
Photo Upload
Photo Upload
Is this incident notifiable?
No
Yes-Worksafe
Yes-EPA
Other
Has Legal Privilege been enacted?
*
Yes
No
ICAM Lead Investigator
*
First
Last
ICAM Team
Target draft report date
Name of EGM completing report
*
First
Last
Date
*
EGM Email
*
Website
Submit report to Hazell Bros Board & Executive
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