Accident/Incident Reporting Form - Australia

This fillable "Accident/Incident Reporting Form" is a document issued by the Australian Department of Health specifically for Australia residents.

Download the PDF by clicking the link below and complete it directly in your browser or through the Adobe Desktop application.

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Accident/Incident Reporting Form
Person Completing this Form
First Name:
Surname:
Preferred contact number:
Position Title/Level:
Signature:
Date: ___ /___ /___
Person Affected
Status of Person Affected:
(please circle/provide detail)
ACT Government Employee
Volunteer Emergency Worker
Third Party:____________________
First Name:
Surname:
Relevant Agency:
Brigade/Unit:
Preferred Contact Number:
Gender:
Email Address:
When did it occur?
Date and Time of Event:
___:___am/pm
___ /___ /___
Duty Officer/Supervisor Name:
Date and Time Duty Officer Notified:
___:___am/pm
___ /___ /___
Where did it occur?
Where did the
Incident/Accident Occur?
(inc.
Map reference, street address etc)
Exact Location of the
Incident/Accident?
(Shed, Truck,
Fireground, Roof, etc)
What happened?
Summary of Incident/Accident:
(inc. details on the outcome of the
Incident/Accident)
Impact of Incident/Accident:
(at
Was this a near miss? .................................................................. 
time of reporting)
No injury or illness, it was a hazardous situation? ...................... 
Minor injury or illness, no time was lost as a result? .................. 
Less than one day of lost work? .................................................. 
One day or more of lost work? .................................................... 
Page 1
Accident/Incident Reporting Form
Person Completing this Form
First Name:
Surname:
Preferred contact number:
Position Title/Level:
Signature:
Date: ___ /___ /___
Person Affected
Status of Person Affected:
(please circle/provide detail)
ACT Government Employee
Volunteer Emergency Worker
Third Party:____________________
First Name:
Surname:
Relevant Agency:
Brigade/Unit:
Preferred Contact Number:
Gender:
Email Address:
When did it occur?
Date and Time of Event:
___:___am/pm
___ /___ /___
Duty Officer/Supervisor Name:
Date and Time Duty Officer Notified:
___:___am/pm
___ /___ /___
Where did it occur?
Where did the
Incident/Accident Occur?
(inc.
Map reference, street address etc)
Exact Location of the
Incident/Accident?
(Shed, Truck,
Fireground, Roof, etc)
What happened?
Summary of Incident/Accident:
(inc. details on the outcome of the
Incident/Accident)
Impact of Incident/Accident:
(at
Was this a near miss? .................................................................. 
time of reporting)
No injury or illness, it was a hazardous situation? ...................... 
Minor injury or illness, no time was lost as a result? .................. 
Less than one day of lost work? .................................................. 
One day or more of lost work? .................................................... 
Page 1
Accident/Incident Reporting Form
Violence/Bullying/Harassment/Discrimination
Was Bullying/ Harassment
Was Discrimination
Was Violence/Abuse Involved?
Y / N
Y / N
Y / N
Involved?
Involved?
If ‘Yes’ to any of the above, please provide detail:
Background to Task
Task Being Performed:
(inc. lead up actions and specific
details of task.)
Experience in
Was appropriate Personal
Yrs:_____
Was Incident/Accident
Trained in
performing
Y / N
Protective Equipment
Y / N
Y / N
related to task?
task?
Mths:____
task?
required/worn?
Corrective Actions
Were any short term corrective
Y / N If ‘Yes’, please provide detail:
or preventative actions taken?
Are any long term preventative
Y / N If ‘Yes’, please provide detail:
actions required?
(inc. Training)
Witness
First Name:
Surname:
Position Title:
Preferred Contact Number:
Person Supervising at Time of Incident
First Name:
Surname:
Position Title:
Preferred Contact Number:
Form entered into RISKMAN by
First Name:
Surname:
Preferred contact number:
Position Title/Level:
Is this Incident/Accident a WorkSafe Notifiable Event? (please circle)
Y / N
Signature:
Date: ___ /___ /___
Privacy Notice:
The information in this form is collected to comply with the ACT Government's responsibilities for recording workplace
accidents/incidents and in accordance with Work Health and Safety Act 2011 as well as:
The Privacy Act 1988 (Cwth). The Privacy Act entitles you to check the record processed from the information you have
provided and to correct any inaccuracies.
The ACT Health Records (Privacy and Access) Act 1997 which outlines the rights of access to records and how they are kept.
The information in this form will only be disclosed to those who have authorisation to receive the information unless written permission
is obtained from the person involved.
Page 2

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