Complaints form

Doc. ID: EAD-EMMS-01-FM-01 Complaints Form Issue Date: Revision Date: Rev. No.:00 09.07.2007 09.07.2007 Page No.: 1 of 1 C000XX/YY (0X) Complaint No.: Date: Time: Name of Complainant : Address : Phone No. : Person Receiving Complaint : :‫رﻗــــﻢ اﻟﺒـــﻼغ‬ :‫اﻟﺘﺎرﻳــﺦ‬ :‫اﻟﻮﻗــﺖ‬ :‫إﺳـﻢ ﻣﻘـﺪم اﻟﺒــﻼغ‬ :‫اﻟﻌﻨــﻮان‬ :‫اﻟﻬـﺎﺗﻒ‬ :‫إﺳـﻢ ﻣـﺪون اﻟﺒـﻼغ‬ :‫ﻤـــﻭﻀــﻭﻉ ﺍﻟﺒــﻼﻍ‬ Area of Complaint: Driving Directions to location ( Please be as exact and specific as possible + GPS Coordinates) :‫ﻣﻨﻄﻘــﺔ وﻗــﻮع اﻟﺒــﻼغ‬ + ‫إرﺷـﺎدات اﻟﻮﺻـﻮل اﻟﻰ اﻟﻤـﻮﻗـﻊ )اﻟﺮﺟـﺎء اﻻﻟﺘـﺰام دﻗـﺔ اﻟﺘﻔـﺎﺻﻴـﻞ‬ (‫إﺣﺪاﺛﻴﺎت اﻟﻤﻮﻗﻊ‬ Description of Action Taken: (‫وﺻـﻒ اﻹﺟـﺮاءات اﻟﺬي ﺗـﻢ اﺗﺨـﺎذهـﺎ ﺑﺸـﺄن اﻟﺒـﻼغ ) ارﻓﺎق اﻟﺘﻘﺎرﻳـﺮ‬ On-Officer Signature: :‫ﺗـﻮﻗﻴـﻊ ﻣـﺪون اﻟﺒــﻼغ‬ (Note that XX: refers to sequence serial code number for case & YY: refers to year last two digits) Doc. ID: EAD-EMMS-01-FM-02 Emergency Notification Form Issue Date: Revision Date: Rev. No.:00 09.07.2007 09.07.2007 Page No.: 1 of 1 E000XX/YY (0X) Date/ Time of Report Date/ Time of Incident Location of Incident GPS Readings Ref. No. Latitude (N) Name Position Contact Longitude (E) Others: Notifier Nature (type) of the Incident Size of the Incident Status of Incident Location Description of Location Identify & Position of Nearest Facility, Tanker, Vessel or Others (if source unknown) Extent of Incident Climate Conditions Responsible Party Spill ( Address Telephone Fax Mobile ) / Fire ( ) / Explosion ( ) / Others ( ), Specify: Small ( ) / Medium ( ) / Big ( ), Others ( ), Specify: Under-Control ( ) / Out-Of- Control ( ) / Others ( ), Specify: Trivial ( ) / Moderate ( ) / Severe ( ) / More, Specify: Name Other Party Incident Controller Initial Response Actions Corrective Actions Images Taken? (Yes/ No) Name Notification Report Prepared By: Title/ Role Contacts Telephone Fax Mobile Photographs Videos Contacts Telephone Fax Mobile Attachments No of Pages (Note that XX: refers to sequence serial code number for case & YY: refers to year last two digits) Doc. ID: EAD-EMMS-01-FM-03 Employee Notice For OH&S Injury-Accident Form Instructions: Issue Date: Revision Date: Rev. No.:00 09.07.2007 09.07.2007 Page No.: 1 of 1 All work-related injuries and occupational illness should be reported in writing. Complete one copy and return to Emergency Management Unit and EAD Safety Officer within 24 hrs to assist in the prompt handling of your case. Location: Employee’s Name: Occupation: Date of Accident: Employee’s ID. #: Date of Birth: Time: am/ pm Describe in detail how injury occurred and what you were doing: Describe in detail which part of the body was injured: Witnessed by: ________________________ Employee’s Signature Date: ____________________ Employee’s Signature Date: Doc. ID: EAD-EMMS-01-FM-04 Witness Form Issue Date: Revision Date: Rev. No.:00 09.07.2007 09.07.2007 Page No.: 1 of 1 Witness Personal Data: Location: Employee’s Name: Occupation: Employee’s ID. #: Accident Investigation: Name of Injured Personnel: Date: Location: Where were you when the accident occurred? What were you doing at that time? What was your response to the accident? What kind of activities took place when the accident occurred? Specify in details? Were you injured? State any other facts about the accident that might be useful during the investigation? _______________________ Witness’s Signature Checked By: EAD Safety Officer ____________________ Date __________________ Doc. ID: EAD-EMMS-01-FM-05 Final Investigation Form Issue Date: Revision Date: Rev. No.:00 09.07.2007 09.07.2007 Page No.: 1 of 4 Section I: Location: A. Summary of Reported Information Injured Employee's Details Sex: Dept.: Employee #: Title: Name: Occupation/ Title: Date of Birth: Supervisor Name: (Note: Find attached Notice for Occupational Injury/ Illness.) B. Description of Injury or Illness Date/ Time: ) Yes ( ) No i. Place of Incident: ii. On EAD Facilities or Field Work Site: ( iii. Reported to: iv. v. Date/ Time: Describe in detail how injury/ illness occurred: Describe affected part of the body and any symptoms: Witnesses to Incident: 1. 2. (Note: Find attached Witness Report.) Doc. ID: EAD-EMMS-01-FM-05 Final Investigation Form Issue Date: Revision Date: Rev. No.:00 09.07.2007 09.07.2007 Page No.: 2 of 4 Section II: Accident Investigation A. Accident Investigation ( ) Yes ( ) No, IF NO, indicate where 1) Agree with Section I information? and explain: 2) 3) Describe Incident (sequence of events) Object or substance causing injury/ illness 4) Were proper personal protective equipment being worn? ( ) Yes ( ) No, IF NO circle equipment that should have been worn: * Goggles * Safety Glasses * Seat Belt 5) ( ) Yes/ ( 6) ( ) Yes/ ( 7) ( ) Yes/ ( 8) ( ) Yes/ ( 9) etc.), ( * Ear Muffs/ Plugs * Gloves * Respirators * Hard Hat (Helmet) * Safety Shoes * Others (Specify) Were proper work procedures being followed? ) No, If No, Explain: Was employee experienced and trained in task? ) No, If No, Explain: Were unsafe tools or equipment involved? ) No, If Yes, Explain: Was employee doing something unsafe? ) No, If Yes, Explain: Were there any Contributing factors (weather, emergency, ) Yes/ ( ) No, If Yes, Explain: 10) First Aid & Medical Treatment. (Provide First Aid & Medical Treatment Reports signed by the physician) Doc. ID: EAD-EMMS-01-FM-05 Final Investigation Form Issue Date: Revision Date: Rev. No.:00 09.07.2007 09.07.2007 Page No.: 3 of 4 Section III: A. Statistical Information ( ) No, If Yes, 1) Fatal? ( ) Yes Date/ Time: 2) Injury/ Illness with recordable lost workdays? ( ) Yes, ( ) No Date returned to regular work activity: 3) Estimated days away: 4) Loss of consciousness? 5) Occupational Illness? If Yes, Indicate Type: 6) Medical Treatment? (Other than First Aid) B. 1) 2) 3) 4) 5) 6) 7) Actual: ( ( ) Yes ) Yes ( ( ) No ) No ( ) Yes ( ) No Injury/ Illness Classification Nature of Injury: Part of Body: Source of Injury: Accident Type: Hazardous Condition: Unsafe Act: Additional Comments: Section I, II & III Reported by: EAD Safety Officer: Date/ Time: Doc. ID: EAD-EMMS-01-FM-05 Final Investigation Form Issue Date: Revision Date: Rev. No.:00 09.07.2007 09.07.2007 Page No.: 4 of 4 Section IV Reviewed By 1. 2. 3. 4. 5. Management Review. Title Head, EAD Emergency OPS Head, EAD Emergency Unit Safety Officer, EAD Date Doc. ID: EAD-EMMS-01-FM-06 Property Damage Form Issue Date: Revision Date: Rev. No.:00 09.07.2007 09.07.2007 Page No.: 1 of 2 Date of Loss: Date of Report: Location: Type of Loss: * * * * / / /200_ /200_ Time: Time: Facility: am/ pm am/ pm Vehicle Theft Malfunction Equipment Failure ( ( ( ( ) ) ) ) * Fire * Leak/ Spill * Explosion *Others, Specify ( ( ( ( ) ) ) ) Describe in details: Cause of Incident/ Accident: Equipment Involved: Personnel Injury/ Extent of Injury(ies): ( ) Minor ( ) Intermediate ( ) Major Number of personnel injured: Doc. ID: EAD-EMMS-01-FM-06 Property Damage Form Issue Date: Revision Date: Rev. No.:00 09.07.2007 09.07.2007 Page No.: 2 of 2 Description of property damaged or destroyed. Estimated cost to repair or replace Services Materials Total estimated to replace/ repair: Recent condition before loss: Estimated Net Loss: Loss Report Prepared by: ________________________ Signature ____________ Date Reviewed By: Head, Emergency Unit: Comments: Date: Approved By: Head, EAD Emergency Operations: Comments: Date: