Environmental Management System

Environmental Incident and Feedback Form

Ref No:
Date:

A. Notification of Environmental Incidents With the Potential to Cause Environmental Harm

1. When an environmental incident occurs IMMEDIATELY NOTIFY SECURITY ON 53333.
Security will notify the Environmental Engineer.
2. As soon as practicable after the incident, complete this form and forward to the Environmental
Engineer, Property and Facilities Division.
You have a duty to notify environmental harm [Section 320, Environmental Protection Act, 1994].
As soon as you become aware of the potential to cause environmental harm, notify the Environmental
Engineer, Property and Facilities by the above method.
Upon notification, the Environmental Engineer will:
Verify the extent and degree of the environmental occurrence;
Advise you of the findings; and
If required under the Environmental Protection Act 1994, the Environmental Engineer will report
the incident to the Queensland Environmental Protection Agency.
Failure to notify environmental harm can attract a penalty of up to $7,500 under the Act.
B.

Feedback on Environmental Issues or Concerns

Excluding Part A, this form should be completed and forwarded to the Environmental Engineer,
Property and Facilities Division when you wish to:
Supply feedback on environmental issues,
Make suggestions on environmental issues, or
Raise a recurring, non-urgent or an incident that has not caused, but had the potential to cause,
environmental harm.

Details of:

A. Environmental Incident
Please provide relevant details below:

B. Feedback/Suggestion

Hazardous Materials Spill

Chemicals
CFC containing equipment
Biological Waste
PCB insulating liquids
Clinical and Related Waste
Radioactive material
Cytotoxic Drugs and Related Waste
Other, please specify: ________________________________________________________________
Type/Ingredient: ___________________________________ Concentration: _________ Quantity: ________

spilt onto ground

contained
not contained
spilt into stormwater drain
contained
not contained
spilt into waterway
container
not contained
poured down sink
poured down sewer
released into atmosphere
caused odour
caused fire/explosion
infectious/contaminated
non-infectious/uncontaminated
public area
non-public area
other, please specify __________________________________________________________________

Environmental Incident and Feedback Form

Issue No. 2

Issue date: 24/03/05

Section 2C

Page 1 of 2

Air Emission
Solvents/ other hazardous substances, or combustion products, please specify:
Type/Ingredient: __________________________________ Concentration: _______ Quantity: ________

Energy Management
Please advise of areas where energy savings can be made, particularly by turning off items when not in use.
Lights
Air conditioning Computers Cold rooms/freezers
Other, please specify _________________________________________________________________
Details __________________________________________________________________________________

Noise
Building site

Entertainment / concert

Sports activities
Other, please specify: _________________________________________________________________

Oil / Fuel Spill

Type (eg. diesel): ________________________________________ Quantity: _________

Contained

Not contained

Waterways
Erosion

Wildlife
Habitat / nesting area disturbed
Other, please specify _________________________________________________________________

Vegetation
Damage to trees/vegetation

Noxious weeds

Contamination, please specify: __________________________

Other comments: _______________________________________________________________________________

______________________________________________________________________________________________

Please complete the following section, submit it to your Head of School/Centre/Organisational Unit for
signature, and send it to the Environmental Engineer, Property and Facilities Division.
Date incident occurred: __________________________________ Time: ________________________________
Reported by: ___________________________ Sch/Ctr ______________________________ Ph: ____________
Location of Environmental Incident:
Site: ________________________ Building: __________________________ Room No. ___________________
Immediate Corrective Action taken: ______________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Follow up Corrective Action to be taken: __________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
If unable to correct problem, please explain: ________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Signature of Head of School/Centre: _________________________________________ Date: _______________
Office Use Only

Action taken:

Date:

File:

Environmental Incident and Feedback Form

Issue No. 2

Issue date: 24/03/05

Section 2C

Page 2 of 2