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INCIDENT REPORT <br /> D <br /> MOTOR VEHICLE ACCIDENT (IF APPLICABLE) <br /> * <br /> Required Fields <br /> Company driver name: Non-company driver name: Weather conditions: <br /> Time of day: Road type: Road surface condition: <br /> Vehicle type: Vehicle model: Vehicle make: <br /> Vehicle year: Registration plate number: Site permit number: <br /> License expiry date: Work hours(number): Company Vehicle: ❑Yes ❑No <br /> Approximate vehicle speed at impact: Length of skid marks: <br /> Vehicle direction of travel: Number of passengers: <br /> P Party involved? ❑Yes ❑No 3` Party driver/passenger: Driver license number: <br /> NEAR MISS(IF APPLICAPLE) <br /> * <br /> Required Fields <br /> High Potential (HIPO) ❑ <br /> *Possible Consequences of the Incident: <br /> ❑ Environmental ❑ Equipment Damage or Loss ❑ Fire <br /> ❑ Residual Hazard/Effect ❑ Injury or Illness ❑ Motor Vehicle Accident <br /> ❑ Security <br /> What happened? (Description of the incident) <br /> What unsafe acts and/or conditions contributed to this incident?(Immediate cause). <br /> Initial Risk Assessment: <br /> Consequence: Probability: <br /> ❑ Insignificant ❑ Rarer <br /> ❑ Minor ❑ Unlikely <br /> ❑ Moderate ❑ Possible <br /> ❑ Major ❑ Likely <br /> ❑ Catastrophic ❑ Almost Certain <br /> SEC'MTY(IF APPLICABLE) <br /> j. <br /> F. <br /> *Required Fields <br /> Type of security: If other type of security incident,please specify: <br /> Security Details: <br /> Victim Details <br /> Is the victim an employee: ❑Yes ❑No Security victim: <br /> Name of victim,if non-employee: Address of victim,if non-employee: <br /> Offender/Suspect Details <br /> Is the offender/suspect an employee: ❑Yes ❑No Security Offender or Suspect: <br /> Name of Offender/Suspect,if non-employee: Gender: <br /> Resolution <br /> Resolution outcome: Resolution property: <br /> Further Details: <br />