Fieldfix Incident Report v2.0

• Document No.

• Audit Title

• Event Location.

  Select Wodonga Launceston Hobart Ballarat Bendigo Melbourne

  • Wodonga
  • Launceston
  • Hobart
  • Ballarat
  • Bendigo
  • Melbourne

• Conducted on

  Date

• Conducted by

  Select Mark Ludbrook Anthony Aloe Craig Newcombe Patrick Cooper Tania Wilson Non ACES Contractor Imagination

  • Mark Ludbrook
  • Anthony Aloe
  • Craig Newcombe
  • Patrick Cooper
  • Tania Wilson
  • Non ACES Contractor
  • Imagination
• Location
  Address

Details

• Is the occurrence an incident, or near miss?

  Incident

  Near miss
Near Miss

• Area description.

  Select Delivery area Outside of loading bay Inside of loading bay Experience Hall Entrance Area Toilets Production Office FOH Office Walkway around Experience hall

  • Delivery area
  • Outside of loading bay
  • Inside of loading bay
  • Experience Hall
  • Entrance Area
  • Toilets
  • Production Office
  • FOH Office
  • Walkway around Experience hall

• Rate the risk factor of the near miss from 1-10 with 1 being low risk and 10 being extremely high risk.

• Who informed you of the Near Miss

• Time of Near Miss

  Date

• Description of Near Miss.

  Requires TRA

  Description
Incident

• Area

  Select Delivery area Outside of loading bay Inside of loading bay Experience Hall Entrance Area Toilets Production Office FOH Office Walkway around Experience hall

  • Delivery area
  • Outside of loading bay
  • Inside of loading bay
  • Experience Hall
  • Entrance Area
  • Toilets
  • Production Office
  • FOH Office
  • Walkway around Experience hall

• Location

• Has the location been secured?

  Yes

  No

  N/A

• Incident type

  Select Medical Property Damage Public Risk Fire Inappropriate Conduct Security Breach Affray Assault Refusal of entry Accessibility issue Distraught patron Theft

  • Medical
  • Property Damage
  • Public Risk
  • Fire
  • Inappropriate Conduct
  • Security Breach
  • Affray
  • Assault
  • Refusal of entry
  • Accessibility issue
  • Distraught patron
  • Theft

• Witness?

  No witness

  Witness name, comments

• Incident details

Hazard Check (If necessary)

• What is the Hazard?

  Select Untidy Work space Obsticles in pathway Vehicular collision Falling Objects Cables No safety railing Unauthorised Access Other

  • Untidy Work space
  • Obsticles in pathway
  • Vehicular collision
  • Falling Objects
  • Cables
  • No safety railing
  • Unauthorised Access
  • Other

• What is the risk?

  Select Trip causing injury Cuts/Abrasions Falling from heights Electricoution Risk of Serious Injury Risk of Death

  • Trip causing injury
  • Cuts/Abrasions
  • Falling from heights
  • Electricoution
  • Risk of Serious Injury
  • Risk of Death

• Suggested solution.

  Hazard Removed

  Hazard Remains

• Add media

  Media

• Is there a follow up required?

  No

  Yes

• Extra drawings or notes.

  Drawing

• Extra Photo's

  Media

Sign off

• Signature

  Sign