Incident Notification Form.

• Document No.

• Incident

• Date

  Date

Incident Location Details

• Date and Time of incident

  Date
• Google Maps location
  Address

• Address Details - if more details needed

• Closest Asciano Workplace

Details of the Person involved

• First name

• Surname

• Address

• Date of Birth

  Date

• Phone Number

• Employee ID number

• Occupation

• Type of employee

  Employee

  Contractor

  Visitor

• Approximate date started role

  Date

• Shift Start time

  Date

Other person involved

• Was another person involved

  Yes

  No

Details of Other Person Involved

• First Name

• Surname

• Address

• Contact Telephone

Details of Incident

• Account of how incident occurred (including witnesses, brief summary leading up to incident). Includes facts about the sequence of events and the conditions existing at the time i.e. lighting, surface, property damage etc.

• Work Activity being undertaken at time of Incident

• Emergency Services Required

  Select Police Ambulance Fire Brigade SES Army Nato

  • Police
  • Ambulance
  • Fire Brigade
  • SES
  • Army
  • Nato

• What immediate actions were taken?

• Reported to Manager

• Manager Name

• Time reported

  Date

Personal Injury Section

• Did personal injury occur

  Yes

  No

Personal Injury Details

• Part of body

  Select Head or Face Arms or Shoulders Back or Trunk Eye Legs or Ankle or Feet Hands or Fingers Neck Hearing Other

  • Head or Face
  • Arms or Shoulders
  • Back or Trunk
  • Eye
  • Legs or Ankle or Feet
  • Hands or Fingers
  • Neck
  • Hearing
  • Other

• Other (description)

• Type of injury

  Select Sprain and Strains Fractures Foreign Matter Crushing Injury Burns Deafness Internal Injury Cuts / Abrasions Other

  • Sprain and Strains
  • Fractures
  • Foreign Matter
  • Crushing Injury
  • Burns
  • Deafness
  • Internal Injury
  • Cuts / Abrasions
  • Other

• Other (description)

• First Aid Treatment

  Select Yes No

  • Yes
  • No

• First Aid Attendants name

Damage to Property Section

• Damage to property occurred

  Yes

  No

Damage to Property Detail

• Describe damage to property - specify Asciano property or other property

• Cost of Damage

• Take photo of damage.

  Media

• Interim actions taken to prevent reoccurrence.

• WorkCover Claim Completed

  Select Yes No

  • Yes
  • No

• SIGN OFF (person completing form) (Print name and sign)

  Sign

• SUPERVISOR/MANAGER (Print name and sign)

  Sign