Mentor: Roman Czujko Cuernavaca, MEX Cuernavaca, MEX Bristol, TN.
MEX WIR Quarterly Workplace Injury Report Form v 2.2
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Transcript of MEX WIR Quarterly Workplace Injury Report Form v 2.2
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8/18/2019 MEX WIR Quarterly Workplace Injury Report Form v 2.2
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ABN: 51 734 124 190Document controller: COMET support www.dpi.nsw.gov.au/minerals/safety MEX-WIR version 2.2 (11 June 2010)
MHSR Quarterly Workplace Injury ReportPursuant to Clause 155 of the Mine Health and Safety Regulation 2007
The operator of a mine must, as soon as practicable, but in any case within 30 days after the end of each quarter ending 31 March, 30 June, 30 September and 31 December,report the information required by this clause to the Chief Inspector in the Gazetted form and manner.
Name of Mine Operator : _______________________________________________________________________________________
Quarter ending :
(please circle)
MarJun
SepDec
Year: 20___
Declaration (mandatory): No work was carried out during the quarter at any mines of this mine operator other than those listed below or in attached additional copies of this form.
W o r k f o r c e I n j u r i e s
Name of Mine (Operators of two or more mines may omit from
this form any mine at which NO work was carriedout during this quarter.)
Type ofworker
Total HoursWorked
Totalnumber
ofworkers
Total number ofnew injuries
(sum of new lost time,restricted duty andmedical treatment
injuries)
Numberof new
lost timeinjuries
Number ofdays lost from
work
Numberof new
restrictedduty injures(not alreadycounted as
lost time)
Number ofdays on
restrictedduties
Number of newmedical treatment
injuries (not alreadycounted as lost timeor restricted duties
Employee days days
Contractor days days
Employee days days
Contractor days days
Employee days days
Contractor days days
Employee days days
Contractor days days
Employee days days
Contractor days days
Employee days days
Contractor days days
Employee days days
Contractor days days
Employee days days
Contractor days days
Employee days days
Contractor days days
Employee days days
Contractor days days
Details of person completing and submitting this form on behalf of the mine operatorName: Employer: Position:
Daytime telephone: Signature: Date:
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