DIAC INCIDENT REPORT

• Client / Site

• Conducted on

  Date

• DIAC name

Notification

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  Date

• Environmental Line Report/Ciram No:

Initial Notifier

• Name:

• Contact number:

Incident description (At time of notification)

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Incident location

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  Address

Substances involved or lost (Product and/or description and quantities involved/lost)

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Agencies notified and/or involved

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Agency Contact

• Select agency

  Select Fire & Rescue NSW Hazmat NSW Police Regional Emergency Mgt Officer Council WorkCover NSW Health Other

  • Fire & Rescue NSW
  • Hazmat
  • NSW Police
  • Regional Emergency Mgt Officer
  • Council
  • WorkCover
  • NSW Health
  • Other

• Agency incoming or outgoing call?

  Select incoming call outgoing call

  • incoming call
  • outgoing call

• Agency Contact Name/Number

• Time of agency contact

  Date

Incident classification

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  Select Level 0 Level 1 Level 2 Level 3

  • Level 0
  • Level 1
  • Level 2
  • Level 3

Handover to Incident Coordinator

• Name/Number:

DIAC Sign off

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  Date

Log of EPA Communications

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EPA Communications Log

• Description of call

• Is it an incoming or outgoing call?

  Select incoming call outgoing call

  • incoming call
  • outgoing call

• Time of call

  Date