ACGC Incident Report / Near Miss

ACGC Incident Report 135 Bundall rd Surfers Paradise QLD 4217

• Incident / Near Miss report number (e.g.IR21122012)

• Incident Title (Name of affected personnel / Patron)

• Incident Location

  Select Arts Theatre The Showroom Lakeside Terrace Panorama Suite The Basement The Space Cafe Terrace Main Foyer Galleries The Lounge Off premises Premises External

  • Arts Theatre
  • The Showroom
  • Lakeside Terrace
  • Panorama Suite
  • The Basement
  • The Space
  • Cafe Terrace
  • Main Foyer
  • Galleries
  • The Lounge
  • Off premises
  • Premises External

• Incident Report Conducted on

  Date

• Incident Report Prepared by

• Incident Report or Near Miss

  Incident Report

  Near Miss

Employee Details

• Gender

  Male

  Female

• Is the Person a

  Employee

  Member of public or visitor

  Contractor or Agency

  Volunteer or work experience

• Employee name

• Employee Payroll Number

• Employee Telephone Number

• ACGC department employee attached to

  Select Technical Programming Function and events Building Services Marketing Administration

  • Technical
  • Programming
  • Function and events
  • Building Services
  • Marketing
  • Administration

• Non Employee name

• Date of Birth

• Non Employee Telephone Number

• Non Employee Address

• Company or Agency name

• Company or Agency telephone number

• Volunteer or Work Experience Name

• Volunteer or Work Experience telephone number

Incident Details

• Date & Time of Incident

  Date

• Date & Time Incident Reported

  Date

• ACGC location of event

  Select Arts Theatre The Showroom Lakeside Terrace Panorama Suite The Basement The Space Cafe Terrace Main Foyer Galleries The Lounge Off premises Premises External

  • Arts Theatre
  • The Showroom
  • Lakeside Terrace
  • Panorama Suite
  • The Basement
  • The Space
  • Cafe Terrace
  • Main Foyer
  • Galleries
  • The Lounge
  • Off premises
  • Premises External

• Provide a description of the incident including injury / illness sustained

• Photo of Damage Or Injury

  Media

Type Of Incident

• Incident or Injury

  Incident Only

  No Injury

  Personal Injury

Treatment ( one or more can be selected )

• Select treatment provided

  Select None First Aid Ambulance Called Hospital Admittance Fatality

  • None
  • First Aid
  • Ambulance Called
  • Hospital Admittance
  • Fatality

• Did the injured person stop work / performance / patronage ?

  Yes

  No

• Date & Time Injured Person Stopped Work / performance / patronage

  Date

• Has the injured person returned to work / performance / patronage ?

  Yes

  No

• Date / time person returned to work / performance / patronage

  Date

• Is the person reporting the incident the injured Employee / Member of Public - Visitor / Contractor or Agency ?

  Employee

  Member of Public or Visitor

  Contractor or Agency

  Volunteer or Work Experience

• Witness name -

• Witness Address

• Witness phone -

• Witness Statement ( include name and contact information )

• Witness Signature

  Sign

Supervisor Information

• Was the immediate supervisor notified ?

  Yes

  No

• Supervisors Signature

  Sign

• ACGC Supervisor payroll number

• ACGC Supervisor phone number

Office Use ONLY

• Date received

• Entered by

• RMIS number