WorkSafe Incident Notification Example
Example document for WorkSafe Incident Notification. Use this as a reference when creating your own.
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Document: WorkSafe Incident Notification
Example Document
Last updated 7/27/2026
WorkSafe Incident Notification Example
1. Notification Details
Date of Notification: 15/10/2023 Time of Notification: 09:15 AM Person Making Notification: Sarah Jenkins Position: Site Manager Contact Number: 0412 345 678
2. Business Details
Business Name (PCBU): BuildRight Constructions Pty Ltd ABN: 12 345 678 901 Trading Name (if different): BuildRight Business Address: 100 Builder Street, Melbourne, VIC, 3000 Workplace Address (if different): 25 Smith Street, Fitzroy, VIC, 3065
3. Incident Details
Date of Incident: 15/10/2023 Time of Incident: 08:45 AM Location of Incident: Rear loading bay, Site B Type of Incident (Select one): [X] Serious Injury or Illness [ ] Death [ ] Dangerous Incident
4. Persons Involved
Name of Injured Person: Michael Ross Age: 34 Gender: Male Role: Labourer Employer: WorkForce Solutions
5. Description of Incident
Describe exactly what happened: The worker was unloading a pallet of bricks from a truck using a forklift. The forklift was reversing towards the loading bay. The worker was walking behind the forklift to guide the driver. The forklift reversed over the worker's right foot. The driver stopped immediately when the worker shouted.
What work was being done at the time: Unloading building materials for stage 2 of the project.
6. Nature of Injury or Dangerous Event
If Injury or Illness: Part of Body Injured: Right Foot Nature of Injury: Crush injury, suspected fractures Medical Treatment Provided: Ambulance called at 08:50 AM. Worker transported to St Vincent's Hospital for surgery.
7. Witnesses
Name 1: David Nguyen Contact Number: 0422 111 222
Name 2: Jenny Wong Contact Number: 0433 444 555
8. Immediate Action Taken
Has the site been secured? Yes Has the incident site been disturbed? No Details of action taken: Area cordoned off with hazard tape. Forklift isolated and keys removed. First aid officer attended to worker until ambulance arrived.
9. Equipment or Substance Involved
Name/Type: Toyota Forklift, Model 8FGU25 Model/Serial Number (if applicable): 45678
10. Regulator Confirmation
Regulator Name: WorkSafe Victoria Reference Number: 12345678 Name of Inspector Spoken To: B. Smith
About this Example
Part of the WorkSafe Incident Notification document collection
Document Type
WorkSafe Incident Notification
A formal notification to the workplace safety regulator regarding a serious injury, illness or dangerous incident that occurs at work.