Incident repot

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Details of Incident

• Date and time incident report created

  Date

• Type of incident

• Accident-involving property damage

• Details of accident involving property damage

• Date and time of accident

  Date

• Details of those involved in accident

Person involved in accident

• Person relationship with event/venue

  Select stakeholder patron employee contractor passerby exhibitor ride operator

  • stakeholder
  • patron
  • employee
  • contractor
  • passerby
  • exhibitor
  • ride operator

• Name

  Sign
• Add location
  Address

• Contact numbers

• Statement

• Photo

  Media

• Near miss

• Details involving near miss

• Date and time of Near Miss

  Date

• Persons involved in near miss

Person involved in near miss

• Relationship with event/venue

  Select stakeholder patron employee contractor passerby exhibitor ride operator

  • stakeholder
  • patron
  • employee
  • contractor
  • passerby
  • exhibitor
  • ride operator

• Statement by person involved in near miss

• Name of person involved in near miss

  Sign
• Address of person involved in near miss
  Address

• Telephone numbers

• Equipment training of person involved

• Licence type and number

• Injury

• Date and time of injury

  Date

• Role of injured person

  Select stakeholder patron employee contractor passerby exhibitor ride operator

  • stakeholder
  • patron
  • employee
  • contractor
  • passerby
  • exhibitor
  • ride operator

• This info is collected blurb

• Signature of person involved in incident

  Sign

• Signed by injured

• Signed by injured person guardian
• Address of person injured or involved in injury/accident or near miss
  Address

• Contact numbers of injured person or guardian:

• Details of how injury occurred:

• Photo

  Media

• Drawing

  Drawing

Equipment involved in incident

• Was equipment involved in incident?

• Operator in control of equipment at time of incident

• Equipment involved in the incident

Equipment number

• Equipment type

• Licences/training by operator at time of incident?

• Is equipment thought to be faulty or did the equipment condition contribute to incident?

• Was the equipment being used correctly as per training?

  Yes

  No

  Unknown

• If not why?

Location of Incident

• Map Reference:

• Area

• Location:

Witness details

• Witnesses

  Yes

  No

• Witnesses

Witness

• Name of witness

• Address of witness
  Address

• Contact telephone numbers:

• Witness statement

Immediate action taken

• Immediate action taken?<br>

  Yes

  No

  No required

• Call for assistance

• Call 000 for ambulance

• Arrangements in place to meet/escort emergency service persons?

• Control room notified

• Has first aid been administered

  Yes

  No

  No required

• Has access to the area been controlled?

• Is evacuated being considered?

• Has the Control Room been advised of incident and repose actions?

• Is action required by other areas

  Yes

  No

  Unknown

• Person required to taken further action

• Action required by others:

• Yes

  No

  N/A

• Electrician

  police

  Security

  Risk Manager

  Event organiser

• Has person been notified?

  Yes

  No

  N/A

• By whom was person notified

Investigate

• Select date

  Date

• Area secured for access

• Action to prevent further injuries

• Details:

• Add media

  Media

Reporting

• Work safe notified completed

• Entered in incident log

• Yes

  No

  N/A