Title Page
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Incident Date
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Prepared by
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Client Name
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Account Manager
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Admin Officer
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Incident Location (Address)
Nature of the Incident
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Provide a brief description of the incident
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Workplace Incident?
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If YES, you must also complete an Incident Hazard Report Form
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WorkCover Claim?
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If YES, you must also complete a WorkCover Claim Form
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Performance/Conduct issue?
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If YES, you must follow the Performance Management Procedure
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Worker hospitalised?
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Worker Charged?
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Alcohol/drugs involved?
Workers Involved
- Workers Involved
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Worker Name
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Group Name
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Action/Outcome (i.e. medical assistance, hospitalisation, arrested, warning isued)
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Number of days off of Work
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Nationality
Incident Details
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Initial Incident Details - Provide detailed description of the incident Include details of injuries sustained, what medical assistance was provided, if a workers compensation claim has been or will be lodged, if any worker's ability to work has been impaired, or they are required to return to light duties, and what measures have been taken to ensure the welfare and wellbeing of workers involved.
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Update 1:
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Update 2:
Involved External Organisation Details
- Involved External Organisation Details
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Organisation Name
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Organisation Address
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Contact Name
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Phone Number
Record of Contact with Involved External Organisations
- Record of Contact with Involved External Organisations
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Date
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Organisation
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Details of Conversation
