EVACUATION CHECKLIST REPORT

This form is to be used by the Security Personnel as an evacuation checklist during an emergency
evacuation. As the Wardens report in to you, record which areas have been cleared and anything
they have to report. This form will help you brief the Emergency Services when they arrive on
scene.

Incident Details
Date:
Security Member:

Start Time:

Finish Time:

JBS Location:

Duration of
Incident:

Fire Alarm (Zone)

Location /
IP Address

Mins

Initial Radio Communication to all Radio Operators

SECURITY TO ALL RADIO USERS AND AREA WARDENS. THIS IS AN EMERGENCY, I REPEAT THIS IS AN EMERGENCY!
IMMEDIATELY EVACUATE YOUR AREA ENSURING ALL PERSONS ARE ACCOUNTED FOR AND
MOVING TOWARD AN EVACUATION ASSEMBLY AREA.
ALL RADIO COMMUNICATIONS ARE TO BE DIRECTED TO SECURITY UNTIL OTHERWISE
INSTRUCTED.
ONCE IN YOUR ASSEMBY AREA CONDUCT HEAD COUNTS AND REPORT TO YOUR AREA
ASSEMBLY WARDEN.

Alerted to Emergency by
Portable Radio:

Telephone:

Name of Reporting Person

Name of Reporting Person

....

....

In Person:

Other (Specify):

Name of Reporting Person

Name of Reporting Person

....

....

Fire Alarm

Burglar Alarm

Emergency
Fire

Armed or Aggressive Intruder

Gas Emission

Building Damage

Explosion

Medical Emergency

Bomb Threat

Flooding

Substance Threat

Blackout Loss of Power

Chemical Spill (Specify:

Other

Assistance Requested
Fire

Alarm Notification

Other .

Fire

Ph: 000

Other .

/var/www/apps/conversion/tmp/scratch_7/332326366.doc

EVACUATION CHECKLIST REPORT

This form is to be used by the Security Personnel as an evacuation checklist during an emergency
evacuation. As the Wardens report in to you, record which areas have been cleared and anything
they have to report. This form will help you brief the Emergency Services when they arrive on
scene.

Ambulance

Ph: 000

Other .

Police

Ph: 000

Other .

Address Location Details for Emergency Services

30 Industry Park Drive, Brooklyn 3012
Closest Cross Street is Trade Place, Brooklyn 3012
Phone: (03) 9316 4480
East 37`48`46 South

GPS Co-Ordinates: 144`50`59

Area (s) Affected

Specify
Specify

WARDEN REPORTS DAY SHIFT

Area
BONING ROOM 1
Area Warden/s & Assembly Warden/s:
Alan Francis - Contact by Radio
Steve Morris Contact by Radio

Evacuation
Assembly

Comments / Contacts

Area 1
Grassed area located
at the Southern part of
the property adjacent
to the Carton Stores

Clear
BONING ROOM 2
Area Warden/s & Assembly Warden/s:

Room Not In Use (4/01/2016)

BONING ROOM 3
Area Warden/s & Assembly Warden/s:
Jason Debrincat Contact by Radio
Rodney Watson Contact by Radio

/var/www/apps/conversion/tmp/scratch_7/332326366.doc

Time: ______

Area 1
Grassed area located
at the Southern part of
the property adjacent
to the Carton Stores

Room Not In Use (4/01/2016)

Clear

Time: ______

Clear

Time: ______

Area 1
Grassed area located
at the Southern part of
the property adjacent
to the Carton Stores

EVACUATION CHECKLIST REPORT

This form is to be used by the Security Personnel as an evacuation checklist during an emergency
evacuation. As the Wardens report in to you, record which areas have been cleared and anything
they have to report. This form will help you brief the Emergency Services when they arrive on
scene.

DMM ROOM
Area Warden/s & Assembly Warden/s:
Najmi Muktar - Contact by Radio

Area 1
Grassed area located
at the Southern part of
the property adjacent
to the Carton Stores

Clear

Time: ______

Clear

Time: ______

Clear

Time: ______

Clear

Time: ______

Clear

Time: ______

CARTON STORE
Area 1
Area Warden/s & Assembly Warden/s:
Jim Tihala - Contact by Radio

Grassed area located

at the Southern part of
the property adjacent
to the Carton Stores

IT / TRAINING OFFICE (PRODUCTION)

Area 1

Area Warden/s & Assembly Warden/s

Mark Muliett IT Contact By Radio or
Mobile: 0400 871 529

Grassed area located

at the Southern part of
the property adjacent
to the Carton Stores

Troy Gray Contact by Radio

BEEF KILL FLOOR

Area Warden/s & Assembly Warden/s
Junior Pierra - Contact By Radio
Yohannes Belaynhe Contact by Radio
Michael McRoberts Contact by Radio

SMALL STOCK KILL FLOOR

Area Warden/s & Assembly Warden/s
George Andonovski - Contact By Radio

/var/www/apps/conversion/tmp/scratch_7/332326366.doc

Area 2
Grassed area located
at the South Eastern
part of the property to
the rear of the
Canteen

Area 2
Grassed area located
at the South Eastern
part of the property to
the rear of the
Canteen

EVACUATION CHECKLIST REPORT

This form is to be used by the Security Personnel as an evacuation checklist during an emergency
evacuation. As the Wardens report in to you, record which areas have been cleared and anything
they have to report. This form will help you brief the Emergency Services when they arrive on
scene.

LOADOUT
Area Warden/s & Assembly Warden/s
Pat Ngaau - Contact By Radio
Grayson Wharenui Contact By Radio

OFFAL ROOM
Area Warden/s & Assembly Warden/s
Nebosja Draskovic - Contact By Radio
Devi Oktavia Contact By Radio

(Afternoon)

LIVESTOCK
Area Warden/s & Assembly Warden/s
Steve Isaacs - Contact By Radio or
Mobile: 0419 400 150
Graham Fennel Contact by Radio

COLLINSONS
Area Warden/s & Assembly Warden/s
Contact Phone: (03) 9318 0755

CANTEEN
Area Warden/s & Assembly Warden/s
Steve Isaacs - Contact By Radio or
Mobile: 0419 400 150
Graham Fennel Contact by Radio

/var/www/apps/conversion/tmp/scratch_7/332326366.doc

Area 2
Grassed area located
at the South Eastern
part of the property to
the rear of the
Canteen

Clear

Time: ______

Clear

Time: ______

Clear

Time: ______

Clear

Time: ______

Clear

Time: ______

Area 2
Grassed area located
at the South Eastern
part of the property to
the rear of the
Canteen

Area 2
Grassed area located
at the South Eastern
part of the property to
the rear of the
Canteen

Area 2
Grassed area located
at the South Eastern
part of the property to
the rear of the
Canteen

Area 2
Grassed area located
at the South Eastern
part of the property to
the rear of the
Canteen

EVACUATION CHECKLIST REPORT

This form is to be used by the Security Personnel as an evacuation checklist during an emergency
evacuation. As the Wardens report in to you, record which areas have been cleared and anything
they have to report. This form will help you brief the Emergency Services when they arrive on
scene.

LAUNDRY / STORES
Area Warden/s & Assembly Warden/s
Steve Isaacs - Contact by Radio or
Mobile: 0419 400 150

AQIS
Area Warden/s & Assembly Warden/s
Hakon Smethurst - Contact By Radio or
Mobile: 0411 364 770

COLD STORES
Area Warden/s & Assembly Warden/s
Jadran Seles - Contact By Radio
Con Visvardis Contact by Radio

DEMATIC
Area Warden/s & Assembly Warden/s
Jadran Seles - Contact By Radio
Con Visvardis Contact by Radio

MAINTENANCE
Area Warden/s & Assembly Warden/s
Craig Evans Plant Engineer
Contact By Radio
Tony Williams - Contact by Radio or
Mobile: 0427 870 254
Matt OBrien / Craig Evans / Charles
Muscat / Wayne Cooper Contact by
Radio

/var/www/apps/conversion/tmp/scratch_7/332326366.doc

Area 2
Grassed area located
at the South Eastern
part of the property to
the rear of the
Canteen

Clear

Time: ______

Clear

Time: ______

Clear

Time: ______

Clear

Time: ______

Clear

Time: ______

Area 2
Grassed area located
at the South Eastern
part of the property to
the rear of the
Canteen

Area 3
Concrete area located
at the Northern part of
the property to outside
the Maintenance
Administration Office

Area 3
Concrete area located
at the Northern part of
the property to outside
the Maintenance
Administration Office

Area 3
Concrete area located
at the Northern part of
the property to outside
the Maintenance
Administration Office

EVACUATION CHECKLIST REPORT

This form is to be used by the Security Personnel as an evacuation checklist during an emergency
evacuation. As the Wardens report in to you, record which areas have been cleared and anything
they have to report. This form will help you brief the Emergency Services when they arrive on
scene.

ELECTRICAL WORKSHOP
Area Warden/s & Assembly Warden/s
Craig Evans - Contact By Radio
Tony Williams - Contact by Radio
Contact Mobile: 0427 870 254

BOILER ROOM
Area Warden/s & Assembly Warden/s
Maintenance Contact by Radio

BY-PRODUCTS (RENDERING)
Area Warden/s & Assembly Warden/s
Bruce Burch - Contact By Phone: (03)
9316 4757 or Radio
Peter Brooks - Contact by Mobile: 0412
833 557 or By Radio
HEAD OFFICE ACCOUNTS
Area Warden/s & Assembly Warden/s
Susan Bacich Contact by Ext 4435

HEAD OFFICE - SALES

Area Warden/s & Assembly Warden/s
Ryan Hodkinson - Contact By Radio

/var/www/apps/conversion/tmp/scratch_7/332326366.doc

Area 3
Concrete area located
at the Northern part of
the property to outside
the Maintenance
Administration Office

Clear

Time: ______

Clear

Time: ______

Clear

Time: ______

Clear

Time: ______

Clear

Time: ______

Area 3
Concrete area located
at the Northern part of
the property to outside
the Maintenance
Administration Office

Area 3
Concrete area located
at the Northern part of
the property to outside
the Maintenance
Administration Office

Area 4
Gravel car park
located at the South
Western part of the
property behind the
Administration Building

Area 4
Gravel car park
located at the South
Western part of the
property behind the
Administration Building

EVACUATION CHECKLIST REPORT

This form is to be used by the Security Personnel as an evacuation checklist during an emergency
evacuation. As the Wardens report in to you, record which areas have been cleared and anything
they have to report. This form will help you brief the Emergency Services when they arrive on
scene.

HEAD OFFICE HUMAN RESOURCES

Area 4

Area Warden/s & Assembly Warden/s

Pauline Vella - Contact by Radio
Contact By Mobile: 0418 830 485

Gravel car park

located at the South
Western part of the
property behind the
Administration Building

Ryan Hodkinson - Contact By Radio

Clear
VALUE ADDED ROOM
Area Warden/s & Assembly Warden/s
Darrel Cody Contact by Radio

Time: ______

Area 1
Grassed area
located at the
Southern part of the
property adjacent to
the Carton Stores
Clear 0 Time: ______

CONTRACTORS
REFER TO CONTRACTOR DAILY
CONTACT LIST

VISITORS
REFER TO CONTRACTOR DAILY
CONTACT LIST

/var/www/apps/conversion/tmp/scratch_7/332326366.doc

Area 5
Area located beside
Gate House

Clear

Time: ______

Clear

Time: ______

Area 5
Area located beside
Gate House

EVACUATION CHECKLIST REPORT

This form is to be used by the Security Personnel as an evacuation checklist during an emergency
evacuation. As the Wardens report in to you, record which areas have been cleared and anything
they have to report. This form will help you brief the Emergency Services when they arrive on
scene.

WARDEN REPORTS AFTERNOON SHIFT

Area
MAINTENANCE
Area Warden/s & Assembly Warden/s
Chris Sharp Contact By Radio

Evacuation
Assembly

Comments / Contacts

Area 3
Concrete area located
at the Northern part of
the property to outside
the Maintenance
Administration Office

Clear
BY-PRODUCTS (RENDERING)
Area Warden/s & Assembly Warden/s
Gary Mather Contact by Radio

COLD STORES
Area Warden/s & Assembly Warden/s
Jadran Seles Contact by Radio

MUTTON KILL FLOOR

Area Warden/s & Assembly Warden/s
N/A

MUTTON BONING FLOOR

Area Warden/s & Assembly Warden/s
N/A

/var/www/apps/conversion/tmp/scratch_7/332326366.doc

Time: ______

Area 3
Concrete area located
at the Northern part of
the property to outside
the Maintenance
Administration Office

Clear

Time: ______

Clear

Time: ______

Area 3
Concrete area located
at the Northern part of
the property to outside
the Maintenance
Administration Office

Area 2
Grassed area located
at the South Eastern
part of the property to
the rear of the
Canteen

Clear

Time: ______

Clear

Time: ______

Area 2
Grassed area located
at the South Eastern
part of the property to
the rear of the
Canteen

EVACUATION CHECKLIST REPORT

This form is to be used by the Security Personnel as an evacuation checklist during an emergency
evacuation. As the Wardens report in to you, record which areas have been cleared and anything
they have to report. This form will help you brief the Emergency Services when they arrive on
scene.

CANTEEN
Area Warden/s & Assembly Warden/s
Graham Fennel - Contact By Radio

LAUNDRY / STORES
Area Warden/s & Assembly Warden/s
Graham Fennel - Contact By Radio

LIVESTOCK
Area Warden/s & Assembly Warden/s
Graham Fennel - Contact By Radio

OFFAL ROOM
Devi Oktavia Contact By Radio

VALUE ADDED ROOM

Leena Mason Contact By Radio

/var/www/apps/conversion/tmp/scratch_7/332326366.doc

Area 2
Grassed area located
at the South Eastern
part of the property to
the rear of the
Canteen

Clear

Time: ______

Clear

Time: ______

Clear

Time: ______

Clear

Time: ______

Clear

Time: ______

Area 2
Grassed area located
at the South Eastern
part of the property to
the rear of the
Canteen

Area 2
Grassed area located
at the South Eastern
part of the property to
the rear of the
Canteen

Area 2
Grassed area located
at the South Eastern
part of the property to
the rear of the
Canteen

Area 1
Grassed area located
at the South Eastern
part of the property to
the rear of the
Canteen

EVACUATION CHECKLIST REPORT

This form is to be used by the Security Personnel as an evacuation checklist during an emergency
evacuation. As the Wardens report in to you, record which areas have been cleared and anything
they have to report. This form will help you brief the Emergency Services when they arrive on
scene.

CLEANERS
Sanikleen Cleaning Max Dahdah
Contact Mobile: 0419 131 634

Area 5
Area located beside
Gate House

Clear

Time: ______

Sanikleen Cleaning Cindy Gordon

Cooke
Contact Mobile: 0458 995 740

Clear

Time: ______

Sanikleen Cleaning Aaron Leyshan

Contact Mobile: 0433 016 034

Clear

Time: ______

Clear

Time: ______

Clear

Time: ______

CONTRACTORS
REFER TO CONTRACTOR DAILY
CONTACT LIST

VISITORS
REFER TO CONTRACTOR DAILY
CONTACT LIST

/var/www/apps/conversion/tmp/scratch_7/332326366.doc

Area 5
Area located beside
Gate House

Area 5
Area located beside
Gate House

EVACUATION CHECKLIST REPORT

This form is to be used by the Security Personnel as an evacuation checklist during an emergency
evacuation. As the Wardens report in to you, record which areas have been cleared and anything
they have to report. This form will help you brief the Emergency Services when they arrive on
scene.

MANAGEMENT ADVISED

Name

Number

Mark Kelly
Plant Manager

0448 005 337

Contact
Time

Not Notified Reason

Instructions: ________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Name

Number

Craig Evans
Plant Engineer

0403 383 625

Contact
Time

Not Notified Reason

Instructions: ________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Name
Victor Patamisi
Chief Fire Warden
(AM Shift)
Jason Spencer
Chief Fire Warden
(PM Shift)

Number

Contact
Time

Not Notified Reason

0411 065 994

0459 026 624

Instructions: ________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

/var/www/apps/conversion/tmp/scratch_7/332326366.doc

EVACUATION CHECKLIST REPORT

This form is to be used by the Security Personnel as an evacuation checklist during an emergency
evacuation. As the Wardens report in to you, record which areas have been cleared and anything
they have to report. This form will help you brief the Emergency Services when they arrive on
scene.

Name
Daniel Mitchell
OHS Officer
Naki Arvanitakis
OHS Officer

Number

Contact
Time

Not Notified Reason

0403 544 021

0423 463 514

Instructions: ________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Name

Number

Contact
Time

Not Notified Reason

Other
Instructions: ________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Name

Number

Contact
Time

Not Notified Reason

Other
Instructions: ________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

/var/www/apps/conversion/tmp/scratch_7/332326366.doc

EVACUATION CHECKLIST REPORT

This form is to be used by the Security Personnel as an evacuation checklist during an emergency
evacuation. As the Wardens report in to you, record which areas have been cleared and anything
they have to report. This form will help you brief the Emergency Services when they arrive on
scene.

EMERGENCY SERVICES IN ATTENDANCE

Fire Brigade

Arrival .... Departure..

Instructions: .

....

Ambulance

Arrival .... Departure..

Instructions: .

....

Police

Arrival .... Departure..

Instructions: .

Other:

Arrival .... Departure..

Instructions: .

/var/www/apps/conversion/tmp/scratch_7/332326366.doc

EVACUATION CHECKLIST REPORT

This form is to be used by the Security Personnel as an evacuation checklist during an emergency
evacuation. As the Wardens report in to you, record which areas have been cleared and anything
they have to report. This form will help you brief the Emergency Services when they arrive on
scene.

CONTACT DETAILS OF EMERGENCY SERVICES PERSONNEL

Emergency Service
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................

Name

Rank
.. .
.. .
.. .
.. .
.. .
.. .
.. .
.. .
.. .
.. .
.. .
.. .

Contact No

DETAILS OF ANY PERSON(S) INJURED

Name
..............................................
..............................................
..............................................
..............................................
..............................................
..............................................
..............................................
..............................................
..............................................

Contact No.
..
..
..
..
..
..
..
..
..

/var/www/apps/conversion/tmp/scratch_7/332326366.doc

Injury Desc
.. . ..
.. . ..
.. . ..
.. . ..
.. . ..
.. . ..
.. . ..
.. . ..
.. . ..

Hospital

EVACUATION CHECKLIST REPORT

This form is to be used by the Security Personnel as an evacuation checklist during an emergency
evacuation. As the Wardens report in to you, record which areas have been cleared and anything
they have to report. This form will help you brief the Emergency Services when they arrive on
scene.

MANAGEMENT IN ATTENDANCE
Name:

Arrival .... Departure ...............

Instructions: .

....

Name:

Arrival .... Departure ...............

Instructions: .

....

Name:

Arrival .... Departure ...............

Instructions: .

....

Name:

Arrival .... Departure ...............

Instructions: .

....

Name:

Arrival .... Departure ...............

Instructions: .

....

Name:

Arrival .... Departure ...............

Instructions: .

....

MEDIA ATTENDANCE
DO NOT PROVIDE MEDIA ACCESS TO SITE INCLUDING CAR
PARKS
DO NOT MAKE ANY COMMENT

/var/www/apps/conversion/tmp/scratch_7/332326366.doc

EVACUATION CHECKLIST REPORT

This form is to be used by the Security Personnel as an evacuation checklist during an emergency
evacuation. As the Wardens report in to you, record which areas have been cleared and anything
they have to report. This form will help you brief the Emergency Services when they arrive on
scene.

BRIEF SUMMARY OF INCIDENT

Duration of Incident:

(Measured from the time of Alarm until staff return to full duties)

/var/www/apps/conversion/tmp/scratch_7/332326366.doc

.. mins

EVACUATION CHECKLIST REPORT

This form is to be used by the Security Personnel as an evacuation checklist during an emergency
evacuation. As the Wardens report in to you, record which areas have been cleared and anything
they have to report. This form will help you brief the Emergency Services when they arrive on
scene.

NOTES

These notes were made by me (Security Officer) in my handwriting at the time or shortly thereafter the emergency
on and are an accurate record of the circumstances surrounding the incident.
Name: .... Signature: . Date: Time: ..

INVESTIGATION: By OH&S of Fire Alarm cause & any Recommendations of same

Investigation Conducted by: (OH&S Officer)

Name: .... Signature: . Date: Time: ..

/var/www/apps/conversion/tmp/scratch_7/332326366.doc