Charter Hall Retail Property Management

Incident Report

• Shopping Centre

• Incident date and time

  Date

• Report completed by -

• Cleaning / Security Company name -

• Location of the incident

  Select Food court General Mall Toilets / amenities Entrance / exit Carpark Pedestrian crossing Loading dock area Garden area Outdoor pathways

  • Food court
  • General Mall
  • Toilets / amenities
  • Entrance / exit
  • Carpark
  • Pedestrian crossing
  • Loading dock area
  • Garden area
  • Outdoor pathways

• Did you see the accident?

  Yes

  No

  N/A

Details of person

• Name

• Gender

  Male

  Female

• Phone number

Incident Investigation

• Cause of incident? (Alleged by person)

  Slip and Fall

  Trip and Fall

  Collision

  Own fault

  Medical Condition

• Description of what happened?

• Description of injury?

  Select No injury reported Minor bruise Graze Sore / swollen Sprain / strain Medical attention required Other

  • No injury reported
  • Minor bruise
  • Graze
  • Sore / swollen
  • Sprain / strain
  • Medical attention required
  • Other

• Treatment?

  Not required

  Treatment refused

  First Aid Treatment

  Ambulance Treatment

  Ambulance to Hospital

Slip Trip and Fall Incident Information Required

• Type of surface?

  Select Terrazzo Tile Timber Vinyl Carpet Pavers Bitumen Concrete Painted crossing Other

  • Terrazzo
  • Tile
  • Timber
  • Vinyl
  • Carpet
  • Pavers
  • Bitumen
  • Concrete
  • Painted crossing
  • Other

• Condition of surface?

  Wet

  Dry

  Uneven

  Slopping

• What was the spill?

  Select Water Soft drink Ice cream Food Oil Other

  • Water
  • Soft drink
  • Ice cream
  • Food
  • Oil
  • Other

• Take five photos of the spill and the area

  Media

• Footwear?

  Select Flat heel shoes High heel shoes Very high heeled shoes Thongs Sneakers Open toe shoe / sandles

  • Flat heel shoes
  • High heel shoes
  • Very high heeled shoes
  • Thongs
  • Sneakers
  • Open toe shoe / sandles

• Condition of footwear?

  Good condition

  Poor condition

Other factors

• Carrying anything at the time?

• Wearing glasses?

• Walking aids being used?

• Under the influence of drugs or alcohol?

Witness to the incident?

• Name and phone number of Witness (1)

• Name and phone number of Witness (2)

Weather?

• Wet weather at the time of incident?

  Yes - Heavy rain

  Yes - Average rain

  Yes - Wet not raining

  No - dry

• Add media

  Media

• Wet floor signs in place?

  Yes

  No

  Not applicable

• Add media

  Media

• Wet weather matts in place?

  Yes

  No

  Not applicable

• Add media

  Media

Other information?

• Other details to be included?

• Add media

  Media

Completion

• Select date

  Date

• Add signature

  Sign