Form 3 "Incident Notification Form" - Queensland, Australia

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Office of Industrial Relations
Form 3
Incident notification form
V20.10.20
Work Health and Safety Act 2011
Safety in Recreational Water Activities Act 2011
Electrical Safety Act 2002
Incident details
Incident type
Please refer to the guide to work health and safety incident notification or electrical safety incident notification web page for assistance.
This is to notify of a:
death
serious injury
serious illness
dangerous incident
serious electrical incident
dangerous electrical event
Provide an explanation of the type of incident using the categories on the guide to work health and safety incident notification or electrical
safety incident notification web page
(e.g. a category of ‘serious injury’ is ‘immediate treatment for serious head injury’):
Incident date, time and location
Date of incident:
Incident address:
Time of incident:
Postcode:
Describe the specific location of the incident
(e.g. aisle 3, plant operation room, tower crane the Elizabeth Street entrance side of the site.)
Description of the incident
Please provide as much detail as possible, for instance: the events that led to the incident; the work being undertaken when
the incident happened; the overall action, exposure or event that best describes the circumstances that resulted in the injury, illness, fatality or dangerous
incident; the object, substance or circumstance which was directly involved in inflicting the injury, illness, death or dangerous incident; the name and type of any
machinery, equipment or substance involved. Was anyone else involved? Was electricity or electrical equipment involved?
(Attach a separate piece of paper if necessary)
Did the incident involve licensed work
(e.g. high risk work, electrical work?)
No
Yes Please provide details of the type of licensed work:
Is the workplace a registered major hazard facility?
No
Yes
Office of Industrial Relations
Form 3
Incident notification form
V20.10.20
Work Health and Safety Act 2011
Safety in Recreational Water Activities Act 2011
Electrical Safety Act 2002
Incident details
Incident type
Please refer to the guide to work health and safety incident notification or electrical safety incident notification web page for assistance.
This is to notify of a:
death
serious injury
serious illness
dangerous incident
serious electrical incident
dangerous electrical event
Provide an explanation of the type of incident using the categories on the guide to work health and safety incident notification or electrical
safety incident notification web page
(e.g. a category of ‘serious injury’ is ‘immediate treatment for serious head injury’):
Incident date, time and location
Date of incident:
Incident address:
Time of incident:
Postcode:
Describe the specific location of the incident
(e.g. aisle 3, plant operation room, tower crane the Elizabeth Street entrance side of the site.)
Description of the incident
Please provide as much detail as possible, for instance: the events that led to the incident; the work being undertaken when
the incident happened; the overall action, exposure or event that best describes the circumstances that resulted in the injury, illness, fatality or dangerous
incident; the object, substance or circumstance which was directly involved in inflicting the injury, illness, death or dangerous incident; the name and type of any
machinery, equipment or substance involved. Was anyone else involved? Was electricity or electrical equipment involved?
(Attach a separate piece of paper if necessary)
Did the incident involve licensed work
(e.g. high risk work, electrical work?)
No
Yes Please provide details of the type of licensed work:
Is the workplace a registered major hazard facility?
No
Yes
Person’s injury/illness and treatment details
(if required)
Title:
First name:
Last Name:
Date of birth:
Contact phone number:
Residential address:
Unit/Building No.
Street No.
Street Name
Suburb/Town/Locality
State
Postcode
Occupation:
(main duties)
Relationship to the entity notifying
Worker
Self-employed
Member of the public
Labour hire worker
Contractor
Group training apprentice/trainee
Other
(please specify):
Description of injury/illness:
(e.g. fracture, laceration, amputation, strain, electrical shock, burn, Q fever)
Body location:
(e.g. wrist, lower back, internal organs):
Did the person receive treatment following the injury/illness?
No
Yes Please describe treatment received:
Where was the injured person
(if applicable)
taken for treatment?
Details of business or undertaking notifying of the incident
Legal name of business:
Trading name of business:
ABN:
ACN:
Business address:
Unit/Building No.
Street No.
Street Name
Suburb/Town/Locality
State
Postcode
Contact phone number:
Work:
Mobile:
Business email address:
Main business activity
(e.g. furniture manufacture, domestic construction, steel warehousing, electrical installation)
Main industry sector
Accommodation and food services
Rental, hiring and real estate services
Mining
Agriculture, forestry and fishing
Transport, postal and warehousing
Public administration and safety
Construction
Administrative and support services
Retail trade
Electricity, gas, water and waste services
Arts and recreational services
Wholesale trade
Health care and social assistance
Education and training
Other services (please specify).
Manufacturing
Financial and insurance services
Professional, scientific and technical
Information media and telecommunication
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Form 3 Incident notification form
ABN 94 496 188 983
Describe any actions taken immediately following the incident to prevent reoccurrence:
Describe any longer term action proposed to prevent a reoccurrence:
Notifier’s details
Title:
First name:
Last Name:
Position at workplace:
Contact phone number:
Email:
Is this the person that should be contacted for further information?
Yes
No If no, please provide the name and contact details of the appropriate person should further information be required.
Mr
Mrs
Miss
Ms
First name:
Last Name:
Position:
Contact phone number:
How to lodge the form
Notification must be by fastest possible means.
Email to whsq.aaa@oir.qld.gov.au.
NOTE: Notification to Workplace Health and Safety Queensland or the Electrical Safety Office is not a notification to WorkCover Queensland.
Call 1300 362 128 if you have any questions about filling out the form. Please keep a copy of this form for your own records before submission.
PRIVACY STATEMENT:
The Office of Industrial Relations respects your privacy and is committed to protecting your personal information. The information provided on this form is for the purpose of advising
Workplace Health and Safety Queensland and/or the Electrical Safety Office of a reportable incident under the Work Health and Safety Act 2011, Electrical Safety Regulation 2002 or Safety in Recreational
Water Activities Act 2011. This information will be managed within the requirements of the current state government privacy regime. Our office may be required to disclose your personal information to
other regulatory agencies such as the Queensland Police Service, WorkCover Queensland and other agencies in accordance with other law enforcement activities which may be conducted as part of an
investigation. Further information on our privacy policy is available at
www.worksafe.qld.gov.au/Privacy.
© State of Queensland 2020
AEU20/5166
Office of Industrial Relations
worksafe.qld.gov.au
1300 362 128
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Form 3 Incident notification form
ABN 94 496 188 983
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