NOTIFIABLE INCIDENT REPORT

SECTION 1: BUSINESS DETAILS

Name of Person Conducting a Business or Undertaking (PCBU): [Legal Name of Business]

ABN: [XX XXX XXX XXX]

Trading Name (if applicable): [Trading Name]

Address of Workplace where incident occurred: [Street Address, Suburb, State, Postcode]

Type of Business: [e.g. Construction, Plumbing, Retail, Manufacturing]

Contact Person for this incident: [Full Name]

Phone Number: [Mobile Number]

Email Address: [Email Address]

SECTION 2: INCIDENT DETAILS

Date of Incident: [DD/MM/YYYY]

Time of Incident: [HH:MM AM/PM]

Location of Incident within Workplace: [Specific area, e.g. Warehouse B, Loading Dock, Level 2]

Type of Notifiable Incident (Tick one):

• Death of a person
• Serious injury or illness of a person
• Dangerous incident

Description of the Incident: [Describe clearly what happened. Include the events leading up to the incident. Do not guess. If you do not know a detail, state 'Unknown'.]

SECTION 3: PERSON INVOLVED DETAILS

Name of Person Involved: [Full Name]

Age: [Age]

Gender: [Male/Female/Other]

Role/Status: [Employee / Contractor / Labour Hire / Visitor / Public]

Occupation: [Job Title]

Employer (if not your business): [Employer Name]

Nature of Injury or Illness: [e.g. Fractured leg, chemical burns, electric shock, no injury]

Body Part Affected: [e.g. Right hand, head, respiratory system, N/A]

Medical Treatment Received: [e.g. Admitted to hospital, first aid on site, transported by ambulance]

Hospital Name (if applicable): [Hospital Name]

SECTION 4: WITNESS DETAILS

Witness Name 1: [Full Name]

Contact Number: [Phone Number]

Witness Name 2: [Full Name]

Contact Number: [Phone Number]

SECTION 5: EQUIPMENT OR SUBSTANCE INVOLVED (if applicable)

Description of Equipment/Machinery: [Make, Model, Serial Number]

Description of Substance: [Chemical name, product name]

SECTION 6: SITE PRESERVATION

Have steps been taken to preserve the incident site? [Yes/No]

Details of site preservation: [Describe what has been done, e.g. area cordoned off, machinery switched off, no access permitted]

Was the site disturbed before notification? [Yes/No]

Reason for disturbance: [e.g. to remove injured person, to prevent fire, to shut down machinery]

SECTION 7: NOTIFICATION

Name of Regulator Notified: [e.g. SafeWork NSW, WorkSafe QLD]

Date of Notification: [DD/MM/YYYY]

Time of Notification: [HH:MM AM/PM]

Inspector Name (if provided): [Name of Inspector]

Inspector Reference Number: [Number]

SECTION 8: DECLARATION

I declare that the information provided in this report is true and correct to the best of my knowledge.

Name: [Full Name]

Position: [Job Title]

Signature: [Signature]

Date: [DD/MM/YYYY]