*Customer Feedback / Incident / Injury Report version 1

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Identification of Incident

• Site Name

  Select Caltex Acacia Ridge Caltex Woolworths Broadbeach Caltex Loganholme Caltex Mackenzie Caltex Marsden Caltex Waterford West Caltex Waterford Caltex Wishart

  • Caltex Acacia Ridge
  • Caltex Woolworths Broadbeach
  • Caltex Loganholme
  • Caltex Mackenzie
  • Caltex Marsden
  • Caltex Waterford West
  • Caltex Waterford
  • Caltex Wishart

• Date and Time incident took place

  Date

• Staff or customer incident.

  Staff

  Customer

• Customer Name, Address,Date of Birth and Contact details

• StaffName, Address,Date of Birth and Contact details

• Where exactly did the incident take place

  Select Forecourt shop Counter Office Storeroom Other

  • Forecourt
  • shop
  • Counter
  • Office
  • Storeroom
  • Other

• Type of Incident

  Select Fire Spill - Fuel or Food Break in Armed Hold Up Personal Injury Other Injury Cutomer Complaint Product Contamination Property Damage Auto Gas Leak Equipment Failure Vandalism Safety / Near Miss other

  • Fire
  • Spill - Fuel or Food
  • Break in
  • Armed Hold Up
  • Personal Injury
  • Other Injury
  • Cutomer Complaint
  • Product Contamination
  • Property Damage
  • Auto Gas Leak
  • Equipment Failure
  • Vandalism
  • Safety / Near Miss
  • other

Incident description

• Describe in detail, how the incident occurred.

• Relevant evidential photos

  Media

Enforcement Authorities & Action

• Treatment Given

  Select First Aid GP Hospital

  • First Aid
  • GP
  • Hospital

• Has the incident been reported to Emergency contacts?

  Select Police Ambulance Fire NA

  • Police
  • Ambulance
  • Fire
  • NA

• Has the incident been reported to Environment Protection Authority?

  Yes

  No

  N/A

• Name and Contact Details of Environment Officer

Cause of incident

• Could this incident have been avoided. Was it foreseeable

  Yes

  No

  N/A

• Addition information / details of Team Leaders observations / comments

Investigation Summary

• Investigation Completed by

  Sign

• Position

  General Manager

  Team Leader

  CSA

  Other