Incident Defect Report

Company

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Name of Person Completing Report*

Contact Phone Number [ (03)xxxx xxxx or (04xx) xxx xxx]*

Rostered Position*

Email Address*

Select the appropriate option*

* An incident is an unplanned event resulting in damage, service interruption, injury, ill health, or other loss.
* A defect is a fault or other imperfection.
* An injury is when the body, or part of the body, is harmed.
* A near-miss is an unplanned event that under different circumstances may have caused damage, service interruption, injury, ill health, or other loss.
* A hazard is a potential source of harm that, if not fixed, may cause an incident or injury

Incident
Hazard
Near Miss / Near Hit
Defect
Injury
Feedback
Complaint
Compliment
Child Safety

Date*

Time*

:

Loco /carriage / trolley #

Train #

Location (i.e. - PBM#, station, level crossing, signal number, building, etc)*

Describe what happened (give information you may consider relevant such as weather conditions, light, body part, direction of car travel, car registration number, etc.)*

What potential contributing factor/s do you believe led to this?*

What action/s did you take?*

Photos (if applicable)

Drop files here or

Max. file size: 256 MB.

DETAILS OF THE INJURED WORKER

Please select the appropriate option IF AN INJURY OCCURED:

No treatment required
Applied first aid
Sought professional medical treatment

Full Name of Injured Worker

Contact Phone Number

Rostered Position (if applicable)

Email Address

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Photos (if required)

Drop files here or

Max. file size: 256 MB.

OTHER PEOPLE / WITNESSES INVOLVED

1) Name

1) Contact Phone Number

1) Rostered Position (if applicable)

1) Email address

2) Name

2) Contact Phone Number

2) Rostered Position (if applicable)

2) Email address

3) Name

3) Contact Phone Number

3) Rostered Position (if applicable)

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3) Name

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3) Contact Phone Number

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3) Rostered Position (if applicable)

3) Email address

Do you need a response to this IDR ?

Yes
No

Name of person completing this form

First Last

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Name of person completing this form

Date*

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DETAILS OF THE INJURED WORKER

OTHER PEOPLE / WITNESSES INVOLVED

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