Field Incident Report

• Document No.

• Field Incident Report

• MonSter Food Truck loCatEd E rock pLaza 4044 e rock blvd LA CA 90065

• Conducted on

  Date

• Prepared by

  Theft pc666

• Personnel

  Select TB’S private security & patrol servicesEmployee Security Response #:

  • TB’S private security & patrol servicesEmployee
  • Security
  • Response #:

Part 1: Incident/ Hazard Details

• Category of Incident:

  Select Personal Injury Property Loss/ Damage Near Miss Hazard Environmental Incident Note Only

  • Personal Injury
  • Property Loss/ Damage
  • Near Miss
  • Hazard
  • Environmental Incident
  • Note Only

• Property Name:

  Select Dexus Property Group Other

  • Dexus Property Group
  • Other

• Is the Building Address 452 Flinders Street Melbourne 3000

  Yes

  No

  N/A

Enter the Description in the field below:

• undefined

Specific area where incident occurred

• undefined

  Select Car Park/ Access Road Tenancy Toilet/ Welfare areas Food Court Mall/ Foyer Roof Loading Dock Landscape areas Lifts/ Escalator Stairwell Plant room Other

  • Car Park/ Access Road
  • Tenancy
  • Toilet/ Welfare areas
  • Food Court
  • Mall/ Foyer
  • Roof
  • Loading Dock
  • Landscape areas
  • Lifts/ Escalator
  • Stairwell
  • Plant room
  • Other

CCTV

• Incident Captured on CCTV

  Yes

  No

  N/A

Incident Type Information

• Incident Type

  Select Slip, trip, fall Person caught in: door Person caught in: plant Person caught in: lift Fall from height Hitting object with body part Flood Property Damage Being hit by moving object Stress Medical Illness Animal Insect Manual handling Fire Electric shock Electrocution Biological Assault Vehicle Death Environmental impact Chemicals and other substances Exposure to mechanical vibration Heat/ Radiation Other

  • Slip, trip, fall
  • Person caught in: door
  • Person caught in: plant
  • Person caught in: lift
  • Fall from height
  • Hitting object with body part
  • Flood
  • Property Damage
  • Being hit by moving object
  • Stress
  • Medical
  • Illness
  • Animal
  • Insect
  • Manual handling
  • Fire
  • Electric shock
  • Electrocution
  • Biological
  • Assault
  • Vehicle
  • Death
  • Environmental impact
  • Chemicals and other substances
  • Exposure to mechanical vibration
  • Heat/ Radiation
  • Other

• Slip, trip fall specific options:

  Select foodscuffs Beverages Steps/ Stairs Rainwater on floor Lack of barrier Slippery surface Uneven surface Tripped over object Poor lighting Other

  • foodscuffs
  • Beverages
  • Steps/ Stairs
  • Rainwater on floor
  • Lack of barrier
  • Slippery surface
  • Uneven surface
  • Tripped over object
  • Poor lighting
  • Other

• Hit by or hitting object specific options

  Select Automatic door Manual door Lift Plant/ Equipment Escalator/ Travelator Other Specify

  • Automatic door
  • Manual door
  • Lift
  • Plant/ Equipment
  • Escalator/ Travelator
  • Other Specify

Observations by author of Incident Report (e.g. Weather, clothing, floor surface conditions) Enter in the below field

• undefined

Part 2: Personal Injury Details (to be completed when category of Incident is Personal Injury)

• Injured Persons Name:

• D.O.B:

• Gender:

  Select Male Female

  • Male
  • Female

• Telephone:

• Email:

• Occupation:

• Person/ Party Identifies as:

  Select Guest/ Visitor/ Public Dexus/ CBRE Employee Tenant Contractor N/A

  • Guest/ Visitor/ Public
  • Dexus/ CBRE Employee
  • Tenant
  • Contractor
  • N/A

• Address:

• Injury Location (body part):

  Select Head Face Eyes Teeth Finger/ Thumb Ankle Multiple/ Various Neck Back Chest Abdominal Leg Unknown Internal Shoulder Arm Wrist Knee Toe Other

  • Head
  • Face
  • Eyes
  • Teeth
  • Finger/ Thumb
  • Ankle
  • Multiple/ Various
  • Neck
  • Back
  • Chest
  • Abdominal
  • Leg
  • Unknown
  • Internal
  • Shoulder
  • Arm
  • Wrist
  • Knee
  • Toe
  • Other

• Nature of Injury:

  Select Contusion/ Bruising Burns Cuts/ Abrasions/ Lacerations Amputation Bites/ Sting Illness Fracture/ Dislocation Musculoskeletal (strain/ sprain) Other

  • Contusion/ Bruising
  • Burns
  • Cuts/ Abrasions/ Lacerations
  • Amputation
  • Bites/ Sting
  • Illness
  • Fracture/ Dislocation
  • Musculoskeletal (strain/ sprain)
  • Other

• Type of Injury:

  Select First Aid only Fatality No Injury Lost Time Injury Medical Treatment Injury Non-work related

  • First Aid only
  • Fatality
  • No Injury
  • Lost Time Injury
  • Medical Treatment Injury
  • Non-work related

• Treatment/ Risk Controls Provided:

• Provided By:

• Treatment Type:

  Select First Aid only Incident/ Near Miss/ No injury Hospital/ Medivac/ Ambulance Medical Practitioner Fire Department (MFB, CFA) Refused

  • First Aid only
  • Incident/ Near Miss/ No injury
  • Hospital/ Medivac/ Ambulance
  • Medical Practitioner
  • Fire Department (MFB, CFA)
  • Refused

• Transportation (if required)

  Select Ambulance Private Vehicle Refused Other

  • Ambulance
  • Private Vehicle
  • Refused
  • Other

Part 3: Property Damage Details (to be completed when Category of Incident is Property Loss/ Damage)

• Nature of Property Event:

  Select Electrical fault/ issue Fire alarm fault/ issue Lift fault/ issue Power outage Weather Damage Façade/ building damage Machinery/ equipment fault Damage- common area Security (theft, vandalism, unauthorised access) Fire Leak/ flood Damage- tenant area Vehicle accident Other

  • Electrical fault/ issue
  • Fire alarm fault/ issue
  • Lift fault/ issue
  • Power outage
  • Weather Damage
  • Façade/ building damage
  • Machinery/ equipment fault
  • Damage- common area
  • Security (theft, vandalism, unauthorised access)
  • Fire
  • Leak/ flood
  • Damage- tenant area
  • Vehicle accident
  • Other

• Cause of Property Event:

  Select Chemical Electrical fault Machinery (fixed plant) External source Human agencies Extreme weather Other

  • Chemical
  • Electrical fault
  • Machinery (fixed plant)
  • External source
  • Human agencies
  • Extreme weather
  • Other

• Tenancy Details (if applicable):

• Name of business contact:

• Telephone:

• Email:

Part 4: Environmental Incident:

• Nature of Environmental Incident

  Emission/ Release

  Water Discharge

  Loss of containment (spill)

  Noise

  Other

• Cause of Environmental Incident:

  Select Chemical Dust Machinery (fixed plant) Noise Tools/ Equipment Other

  • Chemical
  • Dust
  • Machinery (fixed plant)
  • Noise
  • Tools/ Equipment
  • Other

• Impact on Environment:

  Select Air quality decline Evacuation Soil/ ground contamination Water contamination Other

  • Air quality decline
  • Evacuation
  • Soil/ ground contamination
  • Water contamination
  • Other

• Photos attached of scene/ damage (if appropriate)<br>If yes please attach in the below field

  Yes

  No

  N/A

• Photos of Scene/ Damage (if appropriate)

  Media

Part 5: Witness Details (to be completed when possible)

• Witness declined:

  Yes

  No

  N/A

• Witness Name:

• D.O.B:

• Gender:

  Male

  Female

• Telephone:

• Address:

• Describe relationship to Third Party (if any):

• Observations by witness (if any):

Part 6: Report Completion Details (must be completed for each form)

• Reported to (Dexus employee or Security)

  Select TB’S private security & patrol servicesEmployee Security Response #:

  • TB’S private security & patrol servicesEmployee
  • Security
  • Response #:

• Date and Time Reported:

  Date

• Method of reporting:

  Select In Person In Writing Telephone Other

  • In Person
  • In Writing
  • Telephone
  • Other

• Report Completed By:

• Full Name & Signature

  Sign

• Escalated (if required)

  Yes

  No

  N/A

Part 7: Corrective/ Preventative Actions (must be completed for each form)

• Short Term:

• Responsible Person:

• Long Term:

• Responsible Person:

Part 8: Checklist (must be completed for each form)

• Report needs to be provided to site asset management team

  Yes

  No

  N/A

• Incident details need to be sent to Statutory Authority (Worksafe/ Workcover)

  Yes

  No

  N/A

• Is an incident investigation required to be completed for this incident

  Yes

  No

  N/A

• Additional Emergency Response:

  Select None Contractor attended Fire Department attended (MFB, CFA) Police attended Other

  • None
  • Contractor attended
  • Fire Department attended (MFB, CFA)
  • Police attended
  • Other

Please attach additional relevant information or documents, photographs, CCTV Footage, Floor Plans, Security Reports, Cleaning Contracts, and Contractor Agreements etc. as part of your report. This Report is provided as a matter of record only and is not an admission of liability on behalf of Dexus Property Group or its agents.

• Additional Notes (e.g. Follow-up Welfare call)