ENVIRONMENTAL INCIDENT FORM	PF622

All individuals have a duty to notify of environmental harm under the Environmental Protection Act 1994. Use this form to report an incident that may have or threatens to cause environmental harm on University of Queensland premises. 
•	For incidents requiring urgent assistance or response, contact Security on 336 53333.
•	Incidents causing material or serious environmental harm must be reported immediately.
•	Return completed form to Program Manager Environment and Sustainability, Property & Facilities Division.

1.  Notifier’s Details	
Name		Date		
School/Centre		
Faculty/Division		
Contact Details	Phone:	Email:	
2.  Location of Incident 	
Campus/Site		
Building/Locality		
Room No. 		
3.  Incident Details	
Date of incident		Time of incident		
Notifier’s involvement	□
□
□	Involved in the incident
Witness to the incident 
Became aware of the incident	
Description of incident and cause (if known):	
Environmental harm caused		
Response:	
Details of preventative measures required:	

4.  Sustainability Office Use Only	
Assessing Officer		Incident No.		
Type of incident	□
□
□
□	Water
Noise
Hazardous Substances
Other (please specify):	□
□
□
	Waste
Air
Biodiversity
	
Further comments:	
Preventative measures implemented?	Yes  /  No  (please circle)	
Recommended actions	□
□
□	Response satisfactory – no further action required
Further action required (provide details below)
Report to authority (provide details below)	
Further details:	
Signed		Date Closed