Sample Form Contents & Questions

Sample Form Contents & Questions

Selected Form Content/Questions  

Driver Fit For Duty

1.  Tick box (yes/no) response Do you have the correct licence class required?
3 Tick box (yes/no) response Is your licence valid (not cancelled or suspended)?
4 Tick box (yes/no) response Do you understand the requirement for rest periods and have you completed all required rest periods prior to starting this shift?
5 Tick box (yes/no) response Are you impaired by any prescribed or over the counter medications?
6 Tick box (yes/no) response Are you impaired by any alcohol or illegal drugs?
7 Tick box (yes/no) response Is there any reason why you should not be driving?
8 Password Based on your responses you may not be fit to drive. A supervisor code is required to proceed. Supervisor: Enter your password to restart the questions if a mistake has been made and the driver is safe to proceed. Enter the word 'no' if the driver is unsafe for work
9 Text only, no answer  Alert Today - Alive Tomorrow Drive Safe!
10 Text only, no answer This driver is not fit for duty and a replacement must be found. An email alert has been sent to the manager responsible.
11 Tick box (yes/no) response You'll need to select 'Yes' to start again. Make sure you actually read the questions you're answering this time!

Vehicle Prestart

1 Vehicle odometer reading Enter your vehicle odometer reading:
2 Text only, no answer All drivers are legally responsible for the safety and road-worthiness of the vehicles they drive. These checks can save time, expense and reduce the chance of component failure. Inspections should always follow the manufacturer’s recommendations.
3 Check List 1. Engine Compartment - Mark 'Yes' if checked and Ok - Engine oil level,  Engine coolant level,  Clutch fluid level,  Brake fluid level,  Power steering fluid level,  Drive belts
4 Simple text response Add notes about any engine compartment defects you've identified.
5 Check List 2. Electrical - Mark 'Yes' if checked and all Ok - Headlights (high/low), Driving/Fog lights, Park lights, Indicators, Clearance Lights, Tail & Plate lights, Brake lights, Hazard lights
6 Simple text response Add notes about any electrical defects you've identified.
7 Check List 3. Vehicle, Leaks & Load - Mark 'Yes' if checked and all Ok - Vehicle posture, Fluid leaks, Load secured, Air hoses & cables
8 Simple text response Add notes about any Vehicle, Leaks & Load defects you've identified.
9 Check List 4. Vehicle Body - Mark 'Yes' if checked and all Ok - Body damage, Mud flaps and guards, Cabin entry grab handles, Door operation and locks, Windows - operation & damage, Mirrors - lens & security, Plates & signs, Fuel tanks, Air tanks, Toolboxes
10 Simple text response Add notes about any body defects you've identified.
11 Check List 5. Brakes - Check if OK 12 Text only, no answer Alert Today - Alive Tomorrow Drive Safely!


1 Tick box from multi options This is to record a: Minor Injury (onsite first aid only), Serious Injury (medical treatment/ambulance required), Dangerous incident/near miss (no injuries), Other
2 Simple text response Full name, occupation, section/peratment of the person involved. If multiple people are involved a separate form must be filled out for each person.
3 Simple text response Date and time of the incident?
4 Simple text response What is the street address of the incident? (You can describe the location next)
5 Simple text response Describe the exact location the incident took place.
6 Tick box from multi options Who was the incident reported to?
7 Simple text response Names of any witnesses. If there weren't any write 'none'.
8 Simple text response Describe the nature of the incident. Provide as much details as possible. For example: - Events leading up to the incident. - Work being undertaken at the time of the incident. - Objects, substances or circumstances directly involved or contributing to the incident. - Any vehicles, machinery or equipment involved. - Was electricity or electrical equipment involved?
9 Simple text response Describe the bodily location and nature of the injury. Provide as much information as possible. Location - Head/Face/Eyes, Shoulder/Arms, Hand/fingers, Hip/Leg, Foot/Toes, Back, Trunk (other than back), Other. Injury - Superficial, Laceration/cut, Sprain/Strain, Burn, Foreign body, Contusion/crush, Fracture/dislocation,  Internal
10 Tick box from multi options Treatment received/administered - First Aid, Taken to Doctor, Driven to Hospital, Ambulance Called
11 Simple text response Describe details of any first aid given. (up to the point that professional medical treatment commenced if applicable)
12 Tick box (yes/no) response Did/will the injury result in lost time?
13 Signature required I confirm that the answers given are a true and accurate representation of the incident described. 
14 Text only, no answer If there is anything you would like to add you can use the back.
Click the Finish button to complete.

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