Notifiable Incident Report Example
Example document for Notifiable Incident Report. Use this as a reference when creating your own.
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Document: Notifiable Incident Report
Example Document
Last updated 7/29/2026
NOTIFIABLE INCIDENT REPORT
SECTION 1: BUSINESS DETAILS
Name of Person Conducting a Business or Undertaking (PCBU): Apex Masonry Pty Ltd
ABN: 12 345 678 901
Trading Name (if applicable): Apex Masonry
Address of Workplace where incident occurred: 45 Builder Road, Parramatta, NSW, 2150
Type of Business: Construction and Stonemasonry
Contact Person for this incident: John Smith
Phone Number: 0412 345 678
Email Address: john.smith@apexmasonry.com.au
SECTION 2: INCIDENT DETAILS
Date of Incident: 15/10/2023
Time of Incident: 09:45 AM
Location of Incident within Workplace: Rear loading dock, near the stone cutting saw.
Type of Notifiable Incident (Tick one):
- Serious injury or illness of a person
- Dangerous incident
Description of the Incident: The worker was operating the bridge saw to cut a limestone slab. The blade jammed mid-cut. The worker attempted to clear the jam without switching off the machine or isolating the power. The blade restarted suddenly, amputating the worker's index and middle fingers on the left hand. A supervisor immediately applied pressure to the wound and called an ambulance.
SECTION 3: PERSON INVOLVED DETAILS
Name of Person Involved: Michael Brown
Age: 34
Gender: Male
Role/Status: Employee
Occupation: Stonemason
Employer (if not your business): N/A
Nature of Injury or Illness: Amputation of left index and middle fingers.
Body Part Affected: Left hand.
Medical Treatment Received: Admitted to Westmead Hospital for emergency surgery and follow-up care.
Hospital Name (if applicable): Westmead Hospital
SECTION 4: WITNESS DETAILS
Witness Name 1: Sarah Jones
Contact Number: 0422 987 654
Witness Name 2: Unknown (Driver delivering bricks)
Contact Number: Unknown
SECTION 5: EQUIPMENT OR SUBSTANCE INVOLVED (if applicable)
Description of Equipment/Machinery: Titan Bridge Saw, Model TBS-500, Serial Number 12345678.
Description of Substance: N/A
SECTION 6: SITE PRESERVATION
Have steps been taken to preserve the incident site? Yes
Details of site preservation: The power to the bridge saw has been isolated at the switchboard. The area around the saw has been cordoned off with yellow tape. No staff are permitted to enter the area. The saw remains in the exact position it was at the time of the incident.
Was the site disturbed before notification? Yes
Reason for disturbance: The machine was switched off and the injured person was moved to a safer location to receive first aid before the ambulance arrived.
SECTION 7: NOTIFICATION
Name of Regulator Notified: SafeWork NSW
Date of Notification: 15/10/2023
Time of Notification: 10:15 AM
Inspector Name (if provided): Not provided during initial call.
Inspector Reference Number: INC-00998877
SECTION 8: DECLARATION
I declare that the information provided in this report is true and correct to the best of my knowledge.
Name: John Smith
Position: Site Manager
Signature: J Smith
Date: 15/10/2023
Notes
Annotations:
- Section 2: The description is factual and chronological. It does not speculate on why the worker acted that way, only what was observed.
- Section 3: 'Admitted to hospital' confirms the notifiable nature of the injury under the WHS Act.
- Section 6: Explicitly explains why the site was disturbed (to treat the victim) and confirms the equipment was isolated. This shows compliance with the duty to preserve the site.
About this Example
Part of the Notifiable Incident Report document collection
Document Type
Notifiable Incident Report
A formal record used by Australian businesses to notify the WHS regulator of serious workplace incidents like deaths, serious injuries or dangerous events as required by law.