Assessment Method 3
Assessment Method 3
Assessment Method 3
1. Complete the following incident report form on a worker who had a serious slip
and fall from a stage while moving portable stage pieces to erect a drum riser and the
ambulance had to be called.
Site Name
Mackellar girls campus
Site Phone
0433759028
Site Manager Jonathan jones
Site Supervisor at
time Tim Timson
Site Supervisors
Phone No
0347585904
Date of
Incident/Issue 08/08/22
Time of
Incident/Issue 04:36pm
Key issue
Fell from stage
Enter a brief description of the issue
The person had a serious slip and fell from the stage while moving portable stage pieces to erect
a drum riser.
Site Name
Super Bowl
Site Phone
0474850595
Site Manager James Jameson
Site Supervisor at
time James Jameson
Site Supervisors
Phone No
0394858500
Date of
Incident/Issue 23/06/20
Time of
Incident/Issue 07:30am
Key issue
Cut foot from broken glass
Enter a brief description of the issue
The person cut their foot from broken glass left from a previous performance
Signed Date