WorkSafe Incident Notification Form

Use this form to collate information before calling the regulator.

1. Notification Details

Date of Notification: [DD/MM/YYYY] Time of Notification: [HH:MM AM/PM] Person Making Notification: [Full Name] Position: [Job Title] Contact Number: [Phone Number]

2. Business Details

Business Name (PCBU): [Legal Name of Business] ABN: [XX XXX XXX XXX] Trading Name (if different): [Trading Name] Business Address: [Street Address, Suburb, State, Postcode] Workplace Address (if different): [Street Address, Suburb, State, Postcode]

3. Incident Details

Date of Incident: [DD/MM/YYYY] Time of Incident: [HH:MM AM/PM] Location of Incident: [Specific area, e.g., North Block, Level 2, Loading Dock] Type of Incident (Select one): [ ] Death [ ] Serious Injury or Illness [ ] Dangerous Incident

4. Persons Involved

Name of Injured Person: [Full Name] Age: [Age] Gender: [Male/Female/Other] Role: [Job Title, e.g., Electrician, Labourer] Employer: [Name of Company employing the person]

5. Description of Incident

Describe exactly what happened: [Use plain English. Describe the events leading up to the incident, the incident itself, and the immediate aftermath.]

What work was being done at the time? [Description of task]

6. Nature of Injury or Dangerous Event

If Injury or Illness: Part of Body Injured: [e.g., Right Hand, Lower Back] Nature of Injury: [e.g., Fracture, Laceration, Burn, Electric Shock] Medical Treatment Provided: [e.g., Admitted to hospital, First aid only, Ambulance called]

If Dangerous Incident: What was the risk? [e.g., Collapse of crane, release of chlorine gas, fall from 5 metres]

7. Witnesses

Name 1: [Full Name] Contact Number: [Phone Number]

Name 2: [Full Name] Contact Number: [Phone Number]

8. Immediate Action Taken

Has the site been secured? [Yes/No] Has the incident site been disturbed? [Yes/No] Details of action taken: [e.g., Area cordoned off, machinery isolated, emergency services called]

9. Equipment or Substance Involved

Name/Type: [e.g., Forklift, Angle Grinder, Chemical X] Model/Serial Number (if applicable): [Number]

10. Regulator Confirmation

Regulator Name: [e.g., SafeWork NSW, WorkSafe VIC] Reference Number: [Insert number provided by regulator] Name of Inspector Spoken To: [Insert Name]