Information
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Project
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Client / Site
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Serious Incident
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Involving fatality or serious injury or immediately life threatening, phone WorkCover immediately 13 10 50.
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Other Incident
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Involving Workers Compensation claim, lost time payment or not immediately life threatening. Notify WorkCover within 7 days using the o line form at www.workcover.nsw.gov.au or www.workcover.qld.gov.au
About The Incident/Accident/Injury
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When did it happen
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Where did it happen
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Description of what happened
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Was a person injured
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Diagram of area of body where injured
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Name of person injured
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Was the person a
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Persons address
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Emergency contact name/number
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Emergency contact advised
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What led up to the incident
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How exactly was the incident caused
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Did the incident result in the death of the person
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Did the injured person stop work or normal duties
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Date the person stopped working
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Is the person expected to return to work
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What is the expected return to work date
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Is the person likely to return normal duties
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Will a rehabilitation plan be required
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Has a rehabilitation plan been drawn up
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We're there any witnesses
Witness Details
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Were there any witnesses to the incident
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Witness name
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Witness contact details
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Witness name
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Witness contact details
Workplace Managers Report
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Has the incident been investigated
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Corrective action
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Has the corrective action been implemented
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Position
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Select date
Details of Person Conducting Report
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Add signature
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Position
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Details of Follow-up Investigation
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Comments
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Add signature
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Select date
