EPA, South Australia
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This form is used to report radiation incidents to the EPA, and assists in reporting of incidents against the requirements of Schedule 13 of the National Directory for Radiation Protection. Submissions made using this form are confidential and are used by the EPA to assist others in avoiding or preventing future incidents. For information about the type of incidents to be reported using this form, please see our "Radiation Incident Reporting" page, or alternatively you can contact the Radiation Protection Branch at email@example.com or by telephone on 08 8463 7826.
Provide basic details about the incident, including the date and location of the incident, the organisation's name, and whether the source/activity/site was under regulatory control (registered).
Provide more detailed information about the incident here, including the type of incident (medical/non-medical etc.) and as much information about what happened as possible.
Select an incident category from the options below. If no predetermined category is appropriate, select "other" and provide details in the text box below the list.
You need only fill in the category relevant to your selection above. If selecting "other" in any category, please provide details in the text box at the bottom. Once the relevant section is complete, proceed directly to "Worker(s) Involved".
Provide details of the of the worker(s) who were responsible for, or were directly involved with the incident. If there was more than one worker directly involved, please provide the secondary worker details in the additional information field below.
Describe what happened, including leading up to and during the incident. Include circumstances which led to or affected the consequence of the event, what where and when it happened, who was affected, what went badly (or well) that affected the incident, and any other information you consider important.
If the radiation source (activity, equipment and/or apparatus) directly contributed to the cause or severity of the incident (for example - failure of equipment or a batch of radionuclides), provide details of the source below, including its EPA registration number, if known.
Provide details in this section about what caused the incident. You will need to identify the direct or primary cause of the incident (for example, human error), but you can also identify other factors that may have contributed (for example, workload pressures) to the incident. You can only select one direct cause, but you can select as many contributing factors as appropriate.
What was the primary or immediate cause of the incident? Identify the cause from the options below, or use "Other" to provide an alternative.
Did any other factors contribute to the cause of the incident? You can identify multiple contributing factors from the selections below, and/or use "other" to provide alternatives.
Provide an overview of what caused the incident. Include factors which affected the incident outcome such as the effectiveness of existing controls, organisational environment, people’s attitudes and behaviours, learnings from past events, etc.
Provide details about the consequences of the incident, including how many people were exposed as a result of the incident, what dosed were received (if known) and if any harm was caused.
Indicate the number of people exposed as a result of the incident. You can report a near miss incident by selecting "0 - Near Miss" from the list.
For each person that was exposed, indicate if they were occupationally exposed, a patient, or a member of the public. If more than 5 people were exposed, please provide their details in the additional information field below.
Provide details here about the radiation doses people received as a result of the incident. If the doses are unknown, an estimate can be provided using established doses or DRL's for certain procedures. For medical procedures, you can provide the exposure parameters, DAP or DLP if known. If multiple persons were exposed, record the doses as Person 1: 2mSv, Person 2: 3mSv etc. relevant to the persons identified above. You can also include information about how the dose has been estimated/calculated, if required, in each of the fields below.
List the nature of any injuries to each exposed person, such as erythema (burns) to a patient as a result of an extended fluoroscopic procedure. If there was more than 1 person exposed, list as Person 1: erythema, Person 2: no injuries etc. If there were no injuries to any person, you can say no, or none. Additional information regarding injuries can be provided below.
Provide details in this section about what happened immediately after, and in the days following the incident, including actions taken with persons exposed, and preventative measures which were applied afterwards to prevent recurrence.
Provide information such as if the procedure had to be repeated, or if additional medical treatment was required etc.
What actions, such as repairs, clean up of spills, counselling of workers, or other immediate controls have been put in place following the incident?
What preventative measures have been put in place, or what has been done to prevent a similar incident from happening again? You can select as many options as appropriate, and provide additional information below if required.
What actions could be undertaken by your organisation, or other similar institutions which could prevent this type of incident from occurring? Provide at least one recommendation.
Tell us if you believe this incident may have significant learning opportunities and/or be of interest to regulators and other licence holders, or if information about the incident could benefit other organisations. Also let us know if you believe this incident should be reviewed by the EPA as a priority. If you have indicated "Yes" to learnings, please tell us why in the field below.
Are there any additional documents or information that you wish to provide in relation to this incident? For example, you may wish to provide photographs, internal or external reports about the incident, or any other information you think is relevant or helpful. You can upload multiple files, up to 4MB each in size.
To finish, please provide your name, position details, and your contact information, so that we can contact you should we require any further information about this incident.
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