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 *

ABN *

Power and Water contract details

Type of works undertaken for Power and Water *

Your Power and Water contract number *

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

Contractor manager's business unit *

Last health, safety and environmental (HSE) performance meeting with Power and Water representative *

Month Year

Additional comments

Reporting period

The following details should be for those works and activities undertaken on behalf of Power and Water.

Reporting period *

Month Year

Total hours worked for Power and Water in this reporting period *

Number of workers undertaking work on behalf of Power and Water in this reporting period *

Total number of incidents whilst undertaking work on behalf of Power and Water in this reporting period *

Number of notifiable incidents in this reporting period whilst working on behalf of Power and Water * 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 whilst working on behalf of Power and Water * 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.

Number of lost time Injuries (LTI) in this reporting period whilst working on behalf of Power and Water * 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) in this reporting period whilst working on behalf of Power and Water * 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) in this reporting period whilst working on behalf of Power and Water * 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 whilst working on behalf of Power and Water * Hazard is something that could happen with the potential for harm or damage.