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Jumbo Charcoal Event Form
Report any incident, complaint, grievance, or accident by filling in and submitting this form or alternatively an Event Card.
Please notify Environmental Compliance Consultancy (ECC) immediately of any event.
Email:
stephan@eccenvironmental.com
Phone: 081 262 7872
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* Indicates required question
Email
*
Your email
Farm Name
*
Your answer
Farm Number
*
Your answer
Full name(s) of person(s) involved
Your answer
Equipment involved in event
Your answer
Event date
*
MM
/
DD
/
YYYY
Event time
*
Time
:
AM
PM
Reported by (Full Name)
Your answer
Position of person who reported the event
*
Owner/Manager/Producer
Contractor
Employee
Other:
Reported to (Full Name)
Position of person event was reported to
Farm Owner / Manager / Producer
Contractor
Employee
Other:
Clear selection
Was anyone else involved? If so, who?
Your answer
Location where event occurred and camp number/name
*
Your answer
Event type
*
Choose
Damage & Loss
Environment
Legal & Regulatory
Occupational Health & Safety
Reputation
Complaint / Grievance
Is this a repeat event?
*
Yes
No
Event description
*
Your answer
Preliminary findings (what went wrong?)
*
Your answer
What immediate action was taken?
*
Your answer
Was medical attention required?
*
Yes
No
If medical attention was required, explain the treatment was received?
Your answer
Was this a lost time incident? (Lost time incidents are accidents that occur when a worker sustains an injury resulting in time off from work)
*
Yes
No
In the case of lost time incident, how many days was the individual booked off for? (*For example, if an individual was booked off for 2 days, but stayed away from work for 7 days, please enter the number 2)
Your answer
Estimated damage cost in Namibian Dollars
Your answer
Was this event resolved?
*
Yes
No
Send me a copy of my responses.
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