Incident Checklist

• Site conducted

  Select

• Incident Title

• Conducted on

  Date

• Prepared by

• Location
  Address

Incident Details

• Incident Report to be filled out in Issue Register

• Incident Date/Time

  Date

Scene Management

• Make scene safe

  Yes

  No

  N/A

• Preserve scene

  Yes

  No

  N/A

Safety of People

• Ensure a First Aid Person has been contacted to treat any injured persons

  Yes

  No

  N/A

Reporting of incident

• Type of Incident

  Select Medical Treatment Injury First Aid Treatment Near Miss Fire Property Damage Theft Hazard

  • Medical Treatment Injury
  • First Aid Treatment
  • Near Miss
  • Fire
  • Property Damage
  • Theft
  • Hazard

• Contact must be made to Store Manager by attempting to call on the phone

  Yes

  No

  N/A

• Ensure a voice message and/or text message is left on Store Managers Phone

• If Store Manager cant be contacted, contact must be made with Store Owner Piva

• A Text message/Email is adequate in this situation followed by a detailed incident report

• Notify Store manager

• Time incident reported to Store Manager

  Date

• Media used to report to Store Manager

  Select Text Message Email Phone Call

  • Text Message
  • Email
  • Phone Call

• Inspect the incident scene and take notes -What people were involved -What equipment was involved -What are the environmental conditions

• Photography at the scene

  Yes

  No

  N/A

• Drug and Alcohol Test all personnel involved in the incident

  Yes

  No

  N/A

• Collect statements from personnel involved/witnesses

  Yes

  No

  N/A

• Risk Assessment

  Media