1. Incident details
Contractor name/number : (subcontractor-contractor-PDO)/CXXXXXX
Incident owner : Name / Ref Ind
Location : Area / unit - (road/yard/station/rig/hoist/plant etc)
Incident date & time : (d/m/yr) / (24 hour clock) – advise if estimated
Incident type : Fatal, LWC, high potential, significant incident etc
Actual severity rating : Number (1-5) / letter (P, E, A,R) – from RAM
Potential risk rating : Letter (A-E), Number (1-5)/letter (P, E, A,R) from RAM
Description of Injuries : Worst injuries (fractures, head injury, amputation etc)
FIM ID No : Number assigned in FIM
Immediate cause : Short description of what caused harm
Key underlying cause : Main learning from investigation

2. Description of the incident:
This should include the relevant facts explaining what happened including all relevant parties
Leading up to the incident
Immediately before the incident
During the incident
Immediately after the incident
In the emergency escalation of the incident
Important Note:
This should be in sufficient detail to allow a person who does not know anything about the incident to imagine it. It should only be about what happened and not why it happened. Do not include investigation findings here, simply describe the incident as the investigation has shown it happened.
For complex incidents involving the interaction of several different parties, a timeline can be added on a separate slide immediately after this one.

3. Declaration of close out of incident redline recommendations:
The five redlined actions to prevent a reoccurrence in the future have been closed out as follows and I
confirm I have seen appropriate evidence to confirm this by my signature below:
Incident Owner signature: Name/Ref Ind: Date:
_________________________ _______________________ ________________
Recommendation
Action Party (Contractor/PDO)
Description of action taken
Target Date
Date Complete