HTML Preview Drinking Water Quality Incident Report page number 1.
Note: Please refer to the Explanatory notes and instructions for Drinking water quality: incident reporting for further information on completing this form
Office Use Only
DWIID
WSID
Select one box only to describe the type of incident:
For incidents below please complete sections 1, 2, 3, 4 and 5
1. Drinking water service provider details
2. Contact details (for this incident)
Details of telephone report to the regulator
Drinking water quality : incident reporting
Privacy Disclaimer: Collection of information provided in this approved form and any attachments is authorised under the Water Supply (Safety and Reliability) Act 2008
(the Act) and is being used for the purpose of ensuring protection of public health. The Department of Energy and Water Supply will endeavour to maintain any confidentiality
of information relating to your form. However, consideration of your form may involve consultation and if so, details of your form may be disclosed to third parties. This
information will not otherwise be disclosed outside of the department unless required or authorised by law (for example as under the Right to Information Act 2009).
Water Supply (Safety and Reliability) Act 2008, section 630
Part A - (To be completed and submitted within 24 hours of becoming aware of the incident)
Detection of Escherichia coli (E. coli)
Detection of a pathogen
Detection of chemical parameter that does not meet a health guideline value in Australian Drinking Water
Guidelines
Detection of radioactivity exceeding gross alpha and gross beta screening values in Australian Drinking Water
Guidelines
Detection of parameter for which there is no guideline value in the Australian Drinking Water Guidelines
An event or series of events likely to affect drinking water quality or will cause difficulty in ability to adequately
treat drinking water
For incidents below please complete sections 1, 2, 4 and 5
Drinking water service provider
Drinking water scheme
SPID
Email address
Telephone number
( )
Fax number
Contact person
( )
Mobile number
Position
Postal address
Queensland Water Supply Regulator
Form WSR503
V03 Mar 2013
Page 1 of 6
Drinking water service provider
Date reported (dd/mm/yyyy)
/ /
Time reported
AM PM