Contractor Form
Your Details
Reporting Period (month and year)
Business Unit
(select)
Contractor Type
Organisation Name
(select)
Project Name
CP Number
Total Hours Worked (for the reporting period)
Lagging Indicators
No. of Lost Time Injuries (LTI)
APAC classifies an LTI as a workplace injury that resulted in a worker not attending one or more entire rostered day/shift
No. of Medical Treatment Injuries (MTI)
APAC classifies MTI as any injury requiring treatment by a medical practitioner, e.g. doctor, physiotherapist
No. of First Aid Injuries (FAI)
APAC classifies FAI as an injury requiring application of first aid whether by a qualified first aider or use of first aid consumables (e.g. ice pack, bandages)
No. of Near Miss Incidents (NM)
APAC classifies a near miss as any event with the potential to cause an injury has the circumstances been altered
No. of Report Only Incidents (RO)
APAC classifies RO as any event resulting an injury either not requiring treatment, or resulting in medical investigations (e.g. x-rays, MRIs)
No. of Incidents or Injuries That Were Notifiable (to a regulatory authority)
Incidents reportable to regulatory authorities such as WorkSafe Victoria/Tasmania
No. of Improvement or Prohibition Notices Issued by a Regulatory Authority
Improvement Notices or PINs issued by a regulatory authority such as WorkSafe Victoria/Tasmania
Leading Indicators
No. of Safety Inspections Planned
No. of Safety Inspections Completed
No. of Safety Communication Events Planned (E.g. Toolboxes, Safety Meetings, Etc)
No. of Safety Communication Events Completed (E.g. Toolboxes, Safety Meetings, Etc)
No. of Hazards Reported (Does not include hazards reported for rectification to APAC Faults Line)
No. of Hazards Closed out (Does not include hazards reported for rectification to APAC Faults Line)
No. of Safety Initiatives / Achievements Commenced or Completed
Safety Initiatives / Achievements Commenced or Completed (Please Provide Descriptions)
Reporting Sign off
Name of person Completing Form
Position of Person Completing Form
Submit
×
Close
Form could not be submitted :
×
Close
Success :
