INCIDENT / ACCIDENT INVESTIGATION REPORT FORM

• Audit Title ( Claimants Name )

• IRF - Document Number

• Prepared by -

• Please select the Shopping Centre this Incident / Accident Report relates to:

  Select Grand Central Shopping Centre

  • Grand Central Shopping Centre

• Date and time of report:

  Date

• Name of Centre:

  Grand Central Shopping Centre

• Select the date and time of the incident:

  Date

• Select the date and time the incident was reported to the Centre:

  Date

• Enter a brief description of the incident:

• Please choose incident report type:

  Personal Injury

  Medical Incident

  QIC Property Damage

  Tenancy Property Damage

  Vehicle Damage / Incident

• If QIC property damage please enter details:

• Take photos for the report if possible

  Media

• Shop Name:

• Shop Number:

• Store Contact: (full name)

• Contact Number:

• Details of Damage:

• Take photos for the report if possible

  Media

• Claimants Name:

• Claimants Gender:

  Male

  Female

• Claimants Age: (if known or close approximate)

• Claimants Address:

• Home Number:

• Work Number:

• Mobile Number:

• Claimants Name:

• Claimants Gender:

  Male

  Female

• Claimants Age: (if known or close approximate)

• Claimants Address:

• Home Number:

• Work Number:

• Mobile Number:

• Vehicle Make/Model:

• Registration Number:

• Take photos for the report if possible

  Media

HOW DID THE INCIDENT OCCUR ?

• How did the incident occur according to the injured person?

INCIDENT LOCATION DETAILS

• Weather conditions at the time of the incident:

  Select Wet/Raining Dry Sunny Overcast Not applicable

  • Wet/Raining
  • Dry
  • Sunny
  • Overcast
  • Not applicable

• Did the incident occur in a Lift ?

  Yes

  No

• Please use the drop down list

  Select Lift 3 - Near Coffee Club Lift 4 - Near Centre Management Lift 5 - Near Centre Management Lift 8 - Near Credit Union Australia Lift 9 - Kmart Level 0 Carpark Entry Foyer Lift 10 - Kmart Level 0 Carpark Entry Foyer Lift 11 - Goods Lift Duggan St Loading Dock to Level 1 Retail Lift 12 - Goods Lift Duggan St Loading Dock to Level 1 Retail Lift 13 - Big W Goods Lift Lift 14 - Big W Goods Lift Lift 15 - Kmart Goods Lift Lift 16 - Kmart Goods Lift Lift 17 - Retail Bridge Passenger lift Lift 18 - Retail Bridge Passenger lift Lift 19 - Goods lift B.O.H Corridor Retail Bridge Lift 20 - Alford Place (Restaurant Precinct) Lift 21 - Duggan St Loading Dock entry (Mini Major) Lift 22 - Duggan St Loading Dock entry (Mini Major)

  • Lift 3 - Near Coffee Club
  • Lift 4 - Near Centre Management
  • Lift 5 - Near Centre Management
  • Lift 8 - Near Credit Union Australia
  • Lift 9 - Kmart Level 0 Carpark Entry Foyer
  • Lift 10 - Kmart Level 0 Carpark Entry Foyer
  • Lift 11 - Goods Lift Duggan St Loading Dock to Level 1 Retail
  • Lift 12 - Goods Lift Duggan St Loading Dock to Level 1 Retail
  • Lift 13 - Big W Goods Lift
  • Lift 14 - Big W Goods Lift
  • Lift 15 - Kmart Goods Lift
  • Lift 16 - Kmart Goods Lift
  • Lift 17 - Retail Bridge Passenger lift
  • Lift 18 - Retail Bridge Passenger lift
  • Lift 19 - Goods lift B.O.H Corridor Retail Bridge
  • Lift 20 - Alford Place (Restaurant Precinct)
  • Lift 21 - Duggan St Loading Dock entry (Mini Major)
  • Lift 22 - Duggan St Loading Dock entry (Mini Major)

• Take photos of incident area for the report if possible

  Media

• Did the incident occur on an Escalator ?

  Yes

  No

• Please use the drop down list

  Select Esc 5 - Coffee Club Level 1 to Level 2 Esc 6 - Coffee Club Level 2 to Level 1 Esc 7 - Food Court Level 1 to Level 2 Esc 8 - Food Court Level 2 to Level 1 Esc 9 - Level 0 Restaurant Precinct to Level 1 Galleria Esc 10 - Level 1 Galleria to Level 0 Restaurant Precinct

  • Esc 5 - Coffee Club Level 1 to Level 2
  • Esc 6 - Coffee Club Level 2 to Level 1
  • Esc 7 - Food Court Level 1 to Level 2
  • Esc 8 - Food Court Level 2 to Level 1
  • Esc 9 - Level 0 Restaurant Precinct to Level 1 Galleria
  • Esc 10 - Level 1 Galleria to Level 0 Restaurant Precinct

• Take photos of incident area for the report if possible

  Media

• Did the incident occur on a Travelator or Moving Walkway?

  Yes

  No

• Please use the drop down list

  Select Trav 9 - Level 1 (Target) to Level 2 (Coles) Trav 10 - Level 2 (Coles) to Level 1 (Target) Trav 11 - Level 2 (Coles) to Rooftop Carpark Trav 12 - Rooftop Carpark to Level 2 (Coles) Trav 13 - Basement to Level 0 (Kmart) Trav 14 - Level 0 (Kmart) to Basement Trav 15 - Level 0 to 0A Trav 16 - Level 0A to 0 Trav 17 - Level 0A to Level 1 Fresh Food (Woolworths) Trav 18 - Level 1 Fresh Food (Woolworths) to Level 0A Trav 19 - Level 1 Fresh Food (Woolworths) to Level 1A Trav 20 - Level 1A to Level 1 Fresh Food (Woolworths) Trav 21 - Level 1A to Level 2 (Big W) Trav 22 - Level 2 (Big W) to Level 1A Trav 23 - Level 2 (Big W) to Level 2A Trav 24 - Level 2A to Level 2 (Big W) Trav 25 - Level 2A to Level 3 rooftop Carpark Trav 26 - Level 3 Rooftop Carpark to Level 2A

  • Trav 9 - Level 1 (Target) to Level 2 (Coles)
  • Trav 10 - Level 2 (Coles) to Level 1 (Target)
  • Trav 11 - Level 2 (Coles) to Rooftop Carpark
  • Trav 12 - Rooftop Carpark to Level 2 (Coles)
  • Trav 13 - Basement to Level 0 (Kmart)
  • Trav 14 - Level 0 (Kmart) to Basement
  • Trav 15 - Level 0 to 0A
  • Trav 16 - Level 0A to 0
  • Trav 17 - Level 0A to Level 1 Fresh Food (Woolworths)
  • Trav 18 - Level 1 Fresh Food (Woolworths) to Level 0A
  • Trav 19 - Level 1 Fresh Food (Woolworths) to Level 1A
  • Trav 20 - Level 1A to Level 1 Fresh Food (Woolworths)
  • Trav 21 - Level 1A to Level 2 (Big W)
  • Trav 22 - Level 2 (Big W) to Level 1A
  • Trav 23 - Level 2 (Big W) to Level 2A
  • Trav 24 - Level 2A to Level 2 (Big W)
  • Trav 25 - Level 2A to Level 3 rooftop Carpark
  • Trav 26 - Level 3 Rooftop Carpark to Level 2A

• Take photos of incident area for the report if possible

  Media

• Did the incident occur in a common internal or external mall area ?

  Yes

  No

• Please use the drop down list

  Select Level 1 Target to Centre Court Level 1 Lowes Side Mall Level 1 Centre Court to Myer Level 1 Centre Court to Margaret St Level 1 Galleria Level 2 Coles to Centre Court Level 2 Sanity Side Mall Level 2 Centre Court to Myer Level 2 Galleria Level 0 Kmart Common Mall Level 0 Restaurant Precinct Level 1 Woolworths Fresh Food Common Mall Level 1 Restaurant Precinct Level 2 Big W Common Mall

  • Level 1 Target to Centre Court
  • Level 1 Lowes Side Mall
  • Level 1 Centre Court to Myer
  • Level 1 Centre Court to Margaret St
  • Level 1 Galleria
  • Level 2 Coles to Centre Court
  • Level 2 Sanity Side Mall
  • Level 2 Centre Court to Myer
  • Level 2 Galleria
  • Level 0 Kmart Common Mall
  • Level 0 Restaurant Precinct
  • Level 1 Woolworths Fresh Food Common Mall
  • Level 1 Restaurant Precinct
  • Level 2 Big W Common Mall

• If response is other please specify

• Take photos of incident area for the report if possible

  Media

• Did this incident occur in a Centre Carpark?

  Yes

  No

• Please choose car park from the drop down list

  Select Basement Level Carpark Duggan St Level 0 Carpark Victoria St Level 0 Carpark Dent St Level 0 Mezzanine Little St Level 0 Carpark Ramp Hill St Level 0 Carpark ramp Margaret St Level 1 Duggan St Carpark Level 1 Hill St Carpark Level 1 Margaret St Carpark Level 1A Hill St Level 1A Margaret St Level 2 Big (W) Level 2A Hill St Level 2A Margaret St Level 3 Duggan and Little Sts Level 3 Clifford St

  • Basement Level Carpark Duggan St
  • Level 0 Carpark Victoria St
  • Level 0 Carpark Dent St
  • Level 0 Mezzanine Little St
  • Level 0 Carpark Ramp Hill St
  • Level 0 Carpark ramp Margaret St
  • Level 1 Duggan St Carpark
  • Level 1 Hill St Carpark
  • Level 1 Margaret St Carpark
  • Level 1A Hill St
  • Level 1A Margaret St
  • Level 2 Big (W)
  • Level 2A Hill St
  • Level 2A Margaret St
  • Level 3 Duggan and Little Sts
  • Level 3 Clifford St

• Take photos of incident area for the report if possible

  Media

• Did this incident occur at an Auto Door Entry Point ?

  Yes

  No

• Enter the auto door entry point description (and automatic door barcode number if available)

• Take photos of incident area for the report if possible

  Media

• Did this incident occur inside a tenancy?

  Yes

  No

• Please enter tenancy name and shop number

• Take photos of incident area for the report if possible

  Media

• Did this incident occur inside one of the Centre Amenities?

  Yes

  No

• Please use the drop down list

  Select Mens Toilets - Level 1 Existing Female Toilet - 1 Existing Disabled Toilet - Level 1 Existing Parents Room - Level 1 Existing Mens Toilet - Level 2 Existing Female Toilet - Level 2 Existing Disabled Toilet - Level 2 Existing Parents Room - Level 2 Existing Mens Toilets - Level 0 Restaurant Precinct Female Toilets - Level 0 Restaurant Precinct Disabled Toilet - Level 0 Restaurant Precinct Male Toilet - Victoria St Level 0 Female Toilet - Victoria St Level 0 Disabled Toilet - Victoria St Level 0 Parents Room - Victoria St Level 0 Male Toilets - Kmart Corridor Level 0 Female Toilets - Kmart Corridor Level 0 Disabled Toilet - Kmart Corridor Level 0 Parents Room - Kmart Corridor Level 0 Male Toilets - Woolworths Corridor Level 1 Female Toilets - Woolworths Corridor Level 1 Disabled Toilet - Woolworths Corridor Level 1 Parents Room - Woolworths Corridor Level 1 Staff Male Toilet - Behind H&M Level 2 Staff Female Toilet - Behind H&M Level 2 Staff Disabled Toilet - Behind H&M Level 2 Male Toilets - Big W Corridor Level 2 Female Toilets - Big W Corridor Level 2 Disabled Toilet - Big W Corridor Level 2 Parents Room - Big W Corridor Level 2

  • Mens Toilets - Level 1 Existing
  • Female Toilet - 1 Existing
  • Disabled Toilet - Level 1 Existing
  • Parents Room - Level 1 Existing
  • Mens Toilet - Level 2 Existing
  • Female Toilet - Level 2 Existing
  • Disabled Toilet - Level 2 Existing
  • Parents Room - Level 2 Existing
  • Mens Toilets - Level 0 Restaurant Precinct
  • Female Toilets - Level 0 Restaurant Precinct
  • Disabled Toilet - Level 0 Restaurant Precinct
  • Male Toilet - Victoria St Level 0
  • Female Toilet - Victoria St Level 0
  • Disabled Toilet - Victoria St Level 0
  • Parents Room - Victoria St Level 0
  • Male Toilets - Kmart Corridor Level 0
  • Female Toilets - Kmart Corridor Level 0
  • Disabled Toilet - Kmart Corridor Level 0
  • Parents Room - Kmart Corridor Level 0
  • Male Toilets - Woolworths Corridor Level 1
  • Female Toilets - Woolworths Corridor Level 1
  • Disabled Toilet - Woolworths Corridor Level 1
  • Parents Room - Woolworths Corridor Level 1
  • Staff Male Toilet - Behind H&M Level 2
  • Staff Female Toilet - Behind H&M Level 2
  • Staff Disabled Toilet - Behind H&M Level 2
  • Male Toilets - Big W Corridor Level 2
  • Female Toilets - Big W Corridor Level 2
  • Disabled Toilet - Big W Corridor Level 2
  • Parents Room - Big W Corridor Level 2

• Take photos of incident area for the report if possible

  Media

• Did this incident occur in a loading dock?

  Yes

  No

• Please use the drop down list

  Dock 1 - Myer Loading Dock

  Dock 2 - Coles/Target Loading Dock

  Dock 3 - Victoria St Loading Dock

  Dock 4 - Duggan St Loading Dock

• Take photos of incident area for the report if possible

  Media

• Did this incident occur in a Plant Room?

  Yes

  No

• Type location of the plant room

• Take photos of incident area for the report if possible

  Media

• Did the incident involve any Ramps located in Carparks, loading docks etc?

  Yes

  No

• Enter the location of the ramp

• Take photos of incident area for the report if possible

  Media

• Did this incident invlove any areas of the centre roof ?

  Yes

  No

• Enter the location of the roof area.

• Take photos of incident area for the report if possible

  Media

• Any other details. Please Specify?

• Is CCTV Footage available?<br>(If CCTV footage is available please provide a summary of footage, including cleaning activities on the "CCTV notes page")

  Yes

  No

• If no please indicate why ie: no camera in this location

WAS THE INJURED PERSON A CHILD?

• Was the injured person a child ?

  Yes

  No

  N/A

• Aged under 18 years?

  Yes

  No

• Accompanied by an adult?

  Yes

  No

• If accompanied by an adult; Relationship?

  Select Mum Dad Sister Brother Aunty Uncle Cousin Grandmother Grandfather Guardian Carer Family Friend Other

  • Mum
  • Dad
  • Sister
  • Brother
  • Aunty
  • Uncle
  • Cousin
  • Grandmother
  • Grandfather
  • Guardian
  • Carer
  • Family Friend
  • Other

• if Other specify relationship

• Adults Name:

• Address:

• Contact Number:

WHAT INJURIES DOES THE INJURED PERSON ALLEGE THEY SUSTAINED?

• Please choose from the selection - multiples can be selected

  Select Strain / sprain Lacerations / abrasions Contusion (bruise) Fracture / dislocation Hernia Twist Crush injury Soft tissue injury Dental Pain / tenderness Other please specify N/A

  • Strain / sprain
  • Lacerations / abrasions
  • Contusion (bruise)
  • Fracture / dislocation
  • Hernia
  • Twist
  • Crush injury
  • Soft tissue injury
  • Dental
  • Pain / tenderness
  • Other please specify
  • N/A

• If other please specify details

• Part of the body injured - please choose from the selection, multiples can be chosen.

  Select Left side Right side Multiple Hand Wrist Forearm Upperarm Shoulder Elbow Groin Abdomen Chest Hip Head Facial Area Nose Ears Eyes Lower back Middle back Upper back Lower leg Upper leg Neck Foot Ankle Knee Other please specify N/A

  • Left side
  • Right side
  • Multiple
  • Hand
  • Wrist
  • Forearm
  • Upperarm
  • Shoulder
  • Elbow
  • Groin
  • Abdomen
  • Chest
  • Hip
  • Head
  • Facial Area
  • Nose
  • Ears
  • Eyes
  • Lower back
  • Middle back
  • Upper back
  • Lower leg
  • Upper leg
  • Neck
  • Foot
  • Ankle
  • Knee
  • Other please specify
  • N/A

• If other please specify

PRE-EXISTING MEDICAL CONDITION?

• Was the injured person taking medication at the time of the incident?<br>

  Yes

  No

  Unknown

  N/A

• Please enter medications being taken

• Did the person have a pre-existing medical condition or illness at the time of the incident?

  Yes

  No

  Unknown

  N/A

• Please enter details if medical condition or illness

FOOTWEAR BEING WORN BY INJURED PERSON

• Select footwear from drop down list

  Select Flat shoes High Heels Thongs Joggers Work Boots Other N/A

  • Flat shoes
  • High Heels
  • Thongs
  • Joggers
  • Work Boots
  • Other
  • N/A

• If Other please specify

OTHER POTENTIAL IMPEDIMENTS WHICH COULD HAVE CONTRIBUTED TO INJURY

• Is there any other potential impediments which could have contributed to the injury ?

  Yes

  No

  N/A

• Please use the drop down list

  Select Crutches Wheelchair Pregnant Pram Walking Frame Walking Stick Carrying Parcels Other please specify

  • Crutches
  • Wheelchair
  • Pregnant
  • Pram
  • Walking Frame
  • Walking Stick
  • Carrying Parcels
  • Other please specify

• If response is other please enter details

HAS THE INJURED PERSON / TENANT SUFFERED ANY PROPERTY LOSS OR DAMAGE?

• Has the Injured Person/Third Party incurred property loss or damage?

  Yes

  No

• Please use the drop down list

  Select Vehicle Clothing Purchases Tenant Other please specify

  • Vehicle
  • Clothing
  • Purchases
  • Tenant
  • Other please specify

• If other please specifty

• Approximate value of property loss or damage: $

ADDITIONAL INFORMATION

• How did the injured person travel to the Centre?

  Select On foot Drove thier own car Was driven by someone else Taxi Bus Ambulance Wheelchair / Ambulance Other Vehicle ie: motorcycle, mo-ped, bicycle please specify N/A

  • On foot
  • Drove thier own car
  • Was driven by someone else
  • Taxi
  • Bus
  • Ambulance
  • Wheelchair / Ambulance
  • Other Vehicle ie: motorcycle, mo-ped, bicycle please specify
  • N/A

• How did the injured person leave the Centre?

  Select On foot Drove thier own car Was driven by someone else Taxi Bus Ambulance Wheelchair / Ambulance Other Vehicle ie: motorcycle, mo-ped, bicycle please specify N/A

  • On foot
  • Drove thier own car
  • Was driven by someone else
  • Taxi
  • Bus
  • Ambulance
  • Wheelchair / Ambulance
  • Other Vehicle ie: motorcycle, mo-ped, bicycle please specify
  • N/A

TO WHOM WAS THE INCIDENT REPORTED?

• Name:

• Position:

• Contact Number:

HOW WAS THE INCIDENT REPORTED?

• Was the Incident reported by the Injured Person ? <br>

  Yes

  No

• How was the incident reported by the Injured Person?

  Select In person Telephone Email / Letter Reported by a friend or relative

  • In person
  • Telephone
  • Email / Letter
  • Reported by a friend or relative

• Where the Incident is reported by another person? Who reported the incident?<br>(Please enter name, address and contact number)

  In Person

  Telephone

  Letter

  Other

• Name:

• Address:

• Contact Phone Number:

WHERE SLIP/TRIP/FALL, WHAT CAUSED THE INCIDENT, ACCORDING TO THIRD PARTY?

• Provide details of spill or object involved:

• Take photos of incident area for the report if possible

  Media

WERE ANY OTHER PARTIES INVOLVED IN THE INCIDENT?

• Did the incident involve another party or parties?<br>(Specify in notes section how the other party was involved)<br>(Provide Company Name, Address Contact Phone Numbers and their purpose at the centre)

  Yes

  No

• Please specify party from drop down list

  Tenant

  Contractor

  Other

• If other, please specify details here

• Name / Company Name:

• Address

• Contact Phone Number:

TREATMENT OF INJURED PERSONS

• Did the Injured Person require any treatment?

  Yes

  No

  N/A

• Please select from the drop down list

  Select No Medical Treatment First Aid Referred to Doctor Sent to Hospital

  • No Medical Treatment
  • First Aid
  • Referred to Doctor
  • Sent to Hospital

• What was the status of the Injured Person after the incident? (Choose from the list, multiples can be chosen)

  Select Went home Continued with their shopping Transported to Hospital Sent to Doctors

  • Went home
  • Continued with their shopping
  • Transported to Hospital
  • Sent to Doctors

• Was any transport arranged?

  Yes

  No

  N/A

• Please select from the drop down list

  Select Ambulance Taxi Other

  • Ambulance
  • Taxi
  • Other

• If other please specify

• To Where - Please specify

• Was any medical assistance provided at the Centre?

  Yes

  No

  N/A

• Detail the treatment given to the Injured Person:

• Name of person who provided medical assistance:

• Contact number of person who provided medical assistance:

CLEANING AND INSPECTION ARRANGEMENTS (To be completed for all incidents involving slip and fall)

• Enter full name of Cleaning Company

• Full name of Cleaner on duty in the area at the time:

• Were wet weather mats deployed at the time of the incident / Accident?

  Yes

  No

  N/A

• Were wet floor warning signs in place? (Please select)

  Yes

  No

  N/A

• How long before the Incident was the area Inspected/Cleaned in minutes Reviewed by a supervisor in minutes

• Name of the person who did this (if not as above)

• Comments: (eg cleaners outside expected rotation; confirm presence and nature of spillage)

ATTACHMENTS

• Please select all attachments being sent with this report

  Select CCTV footage Photographs Witness/cleaners statements Map Wand reports Correspondence Service/maintenance report

  • CCTV footage
  • Photographs
  • Witness/cleaners statements
  • Map
  • Wand reports
  • Correspondence
  • Service/maintenance report

ANY OTHER COMMENTS?

• Other commentary may include was the site investigated, was the injured person involved in a prohibited activity, does the injured person's version not seem plausible?

WHAT IS THE LIKELY OUTCOME OF THE INCIDENT?

• Please select from the list:

  Incident Only

  Claim for costs may arise

  Litigation may arise

  Workplace Health & Safety issues may arise

CCTV OR PROBE IDENTIFICATION COMMENTS

• Make detailed notes here:

• Full name of person making notes:

WERE THERE ANY WITNESSES TO THE INCIDENT ? Please have each witness complete the witness statement section below?

• Was there any Witness Statements to be made?

  Yes

  No

• Full Name:

• Address:

• Date of Birth:

• Statement: (must commence with I )(name of person making statement)(state as follows:)

• Your information will be dealt with as per our Privacy Policy (available at the Customer Service Desk or the Centre Management Office within the centre). The Privacy Policy contains information relating to access and collection of personal information, about how you may complain about a breach of the Australian Privacy Principles and how we will deal with such a complaint and your information is being collected for the purposes outlined in our Privacy Policy. The personal information is being collected for the purpose of investigating and responding to the incident and that the information may be disclosed to the team which manages incidents for the Centre as well as third party advisors and consultants who provide advice to the owner/s of the Centre in relation to the incident.

• Signature of person making statement

  Sign

• Date and time of signature:

  Date

• Signature of person witnessing statement:

  Sign

• Date and time of witness signature:

  Date

PRIVACY REQUIREMENTS (for injured person, witness, persons who suffered property damage)

• Person advised that their information was being collected for the purpose of investigating and responding to the incident and that, with their consent, the information may be disclosed to the team which manages incidents for the Centre as well as other organisations.<br>

  Yes

  No

• If No please provide details

• Please enter the the name of the person who so advised the injured person, witness or persons who suffered property damage.

PERSON WHO COMPLETED THE REPORT:

• I confirm that I have read this report and am satisfied that the details provided are to the best of my knowledge, accurate at the time of completion.

  Confirm

  Deny

• Signature of person who completed the report:

  Sign

OTHER COMMENTS/DIAGRAM:

• PROVIDE SKETCH OR OTHER DRAWING HERE:

  Drawing

OPERATIONS MANAGERS COMMENTS AND SIGN OFF

• Operations Managers comments:

• Simon Wilkinson

  Sign