Time of incident Nature of incident Name of injured person Address Occupation

Time of incident nature of incident name of injured

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Time of incident Nature of incident Name of injured person Address Occupation Date of birth Telephone Employer Activity in which the person was engaged at the time of injury Exact site location where injury occurred Nature of injury – eg fracture, burn, sprain, foreign body in eye Treatment given on site Referral for further treatment? Yes No Injury management required? Yes No Witness to incident (each witness may need to provide an account of what happened) Witness name Witness name Details of incident (eg property, plant or environmental damage) Date of incident Time of incident am pm Location of incident Details of damage to Equipment or property Name of person who Telephone Received the report
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Description of incident Immediate response actions (eg barricades, isolation of power) to stabilise the situation Reported to Reported to principal contractor? Yes No Reported to authorities (WorkCover phone: 13 10 50 )? Yes No Reported to principal contractor? Yes No Reported to workers compensation insurer? Yes No Completed by Name Signature
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WHS Administrator to complete: Comments on the cause and nature of the accident: Action taken to prevent a recurrence: Date of Incident: / / Time of Incident : am/pm (Signature of Employee) (Date)
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ADDENDUM | © 2019 YOUNG RABBIT PTY LTD, AUSTRALIAN PACIFIC COLLEGE BSB20115 CERTIFICATE
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