Monthly contractor HSE report form

Our Power and Water contractors are required to report monthly in relation to works carried out for Power and Water by submitting this health, safety and environmental reporting form by the 7^th day of each calendar month.

Contractor's details

Given name/s *

Family name *

Phone number *

Email *

Business name *

Power and Water contract details

Your Power and Water contract number *

Your Power and Water point of contact * Contractor manager name.

Additional comments

Reporting period

This report is only for works and activities undertaken on behalf of Power and Water. Complete the form for the previous calendar month only (for example: if you are submitting in September, report on activities from August).

Reporting period *

Month Year

Total hours worked *

Number of workers undertaking work *

Total number of incidents *

Incident descriptions (brief titles) *

Number of regulator-notifiable incidents * Any incident that is notifiable to a regulator including NT WorkSafe, NT Environmental Protection Authority, Department of Environment, Parks and Water Security, NT Health, Utilities Commission, Police or other prescribed agency.

Number of regulatory notices or formal directives * Regulatory notices or formal directives received from a regulator including NT WorkSafe, NT Environmental Protection Authority, Department of Environment, Parks and Water Security, NT Health, Utilities Commission, Police or other prescribed agency.

Notice or directive descriptions (brief titles) *

Number of lost time Injuries (LTI) * Lost time injury (LTI) is a work-related injury or illness certified by a medical practitioner that results in the absence from work for at least one scheduled day or shift.

Number of medical treatment injuries (MTI) * Medical treatment injury (MTI) is defined as a work-related injury or illness that resulted in a certain level of medical treatment (not first aid treatment) provided by a physician or other medical personnel.

Number of first aid injuries (FAI) * First aid injury (FAI) is defined by treatment administered by and within the qualifications of a trained first aid attendant or Occupational Health Nurse.

Number of hazards in this reporting period * Hazard is something that could happen with the potential for harm or damage.

Last updated: 07 Nov 2025