Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Incident Location
  • CMIS Case Number

Details of Incident

  • Date and Time

  • Notified by

  • Details

  • Site Contact - Name

  • Phone

Location

  • Address

  • Suburb

  • Occupier of Premises

  • Date of Birth

  • Type of Premises

  • Form of Energy

  • Type of Incident

  • Site Contact - Name and Phone Number

Notification

  • Manager / Duty Manager

  • Executive Manager

  • Director

  • CAMS

  • Work-Safe

  • Other

ESV Attendance at Scene

  • Event / Incident Location
  • ESV attendance at scene

  • Do you require further resources / staff to assist?

Summary of Event/Incident

  • Summary of Scene

Sketch of Scene

  • Sketch of Scene

Details of Person Onsite

    Person Details
  • Who is incharge on the site?

  • Name

  • Station

  • Phone Number

  • Ref Number

  • Other Details

  • Name

  • Licence Number

  • Contact Number

  • GFN/COC Number

  • Name

  • Address

  • Date of Birth

  • Phone Number

  • Email

  • Add Appliance & Vehicle Details
  • Appliance Type

  • Appliance Number

  • Type

  • Make

  • Model

  • Is a Vehicle/Mobile Plant involved?

  • Type

  • Make

  • Model

Incident/Event Check-list

Initial Attendance at Incident - CHANGE RESPONSES

  • Ensure you have appropriate OH&S gear

  • Determine if investigation is technical or legal

  • Wear identification

  • Ensure scene is preserved

  • Liaise with officials at scene and obtain details

  • Complete Investigation checklist

  • Establish the cause of incident

  • Determine whether Statute / Regulations have been breached

  • Identify Exhibits – for court and analysis

  • Identify witnesses and obtain details

Conduct Incident Scene Examination

  • Take readings and record

  • Observe and sketch scene

  • Photograph scene (prior to touching or moving any objects)

  • Search scene

  • Photograph exhibits as located

  • Measure location of exhibits

  • Collect / Label exhibits individually as located

Prior to Leaving Scene

  • If serious incident –briefing of Manager Investigations / Executive Manager

  • Have you been released by the Officer in charge (VICPOL / MFB / CFA)?

  • Organise time and date for witnesses to have statements obtained

  • Do you or other staff require debrief (EAP)? – Contact Manager or individually

  • Ensure you have all your equipment

At the Office / Post-Event Details

  • Enter details into CIMS/PEGA

  • Create hard file

  • Obtain witness statements

  • Enter Details into Investigation Plan

  • Upload all files to CIMS/PEGA

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.