UC Incident Report

• Report Title

• Report Conducted on

  Date

• Report Prepared by

  Sign
• Location
  Address

• Time incident occurred

  Date

Type of Incident

• Select Personal Injury Building Fire (incl alarm) Grass / Garden Fire Car Fire Motor Vehicle Accident Property Loss (individual) Property Loss (UC property) Crime against Person Gas leak or other HAZMAT Flood (water ingress) Other

  • Personal Injury
  • Building Fire (incl alarm)
  • Grass / Garden Fire
  • Car Fire
  • Motor Vehicle Accident
  • Property Loss (individual)
  • Property Loss (UC property)
  • Crime against Person
  • Gas leak or other HAZMAT
  • Flood (water ingress)
  • Other

Incident Description

• Describe how incident occurred

• Describe who is / may be impacted across University

Actions undertaken to resolve Incident

• Describe UC rectification actions

• Person(s) notified via escalation process

Incident Location

• Describe where incident occurred

• Google map & GPS location
  Address

• Check box if incident occurred within a building

• Building number

• Floor

  A

  B

  C

  D

  Other

• Room number

• Images of incident location

  Media

Personnel responding

• UC Security

  Yes

  No
Person

• Name

• UC Staff

  Yes

  No
Person

• Name

• Emergency Services?

• ACT Fire Brigade

  Yes

  No

• ACT Police

  Yes

  No

• ACT Ambulance service

  Yes

  No

• ACT State Emergency Service

  Yes

  No

• Other Respondants (including contractors)?

• Safety Authority (including ORS inspector, Health inspector and other Government inspectors)

  Yes

  No

• Energy Authority

  Yes

  No

• Gas Authority

  Yes

  No

• Water Authority

  Yes

  No

• Other (including contractors)

  Yes

  No
Company details

• Company name and personnel

Source of alarm

• Check box if alarm activation notified UC of incident

• Smoke detector?

  Yes

  No

• Thermal detector?

  Yes

  No

• Sprinkler?

  Yes

  No

• Break Glass Alarm (Manual Call Point)?

  Yes

  No

• Vesda?

  Yes

  No

• Security Alarm?

  Yes

  No

• Other (including phone calls)?

  Yes

  No
Caller ID

• Caller name and phone number

Fire Details

• Check box if there was a fire associated with the incident?

• Electrical

  Yes

  No

  N/A

• Ordinary combustibles

  Yes

  No

  N/A

• Flammable liquid

  Yes

  No

  N/A

• Other (including vehicle)

  Yes

  No

  N/A

Injuries

• Check box if injuries were reported

• UC Staff

  Yes

  No

  N/A
Injured Party Details

• Name

• Contact Phone Number

• Staff Number

• Detail of injuries

• UC Student(s)

  Yes

  No

  N/A
Injured Party Details

• Name

• Contact Phone Number

• Student number

• Detail of Injuries

• Visitors

  Yes

  No

  N/A
Injured party details

• Name

• Contact phone number

• Reason for visit to University of Canberra

• Detail of Injuries

Witness statement(s) relating to the incident

Witness statement

• Name

• Contact Phone Number

• Statement

Further images related to incident

• Other Images

  Media

Sign off

• Signature

  Sign

• Time report completed

  Date