Notification of Health & Safety Incident

• Document No. US20120918

• Site / Client / Patrol Run (Call Sign)

• Employee's Full Name:

• Report Conducted on:

  Date

• Report Prepared by:

• Location
  Address

• Personnel

• A Notification of incident must be completed IMMEDIATELY by the worker. for ALL work-related incidents, regardless of their nature.
  If a worker in unable to complete form, the Supervisor / Manager is responsible for the completion and forwarding as per US20130318 Procedure 11a Compensation Injury Claim.

• -------------------- In accordance with Workplace Health and Safety Legislation --------------------

WHAT

• Incident Severity:

  Select Death / Serious Injury Lost Time Medical Treatment Required First Aid Required Near Miss Sickness / Illness

  • Death / Serious Injury
  • Lost Time
  • Medical Treatment Required
  • First Aid Required
  • Near Miss
  • Sickness / Illness

• Date and Time of Incident:

  Date

• Date Reported to Company:

  Date

PERSON

• Family Name: (Surname)

• Given Names:

• Contact Number: Home

• Contact Number: Mobile

• Date of Birth:

  Date

• Address: No. & Street:

• Suburb:

• Post Code:

• Division: (Guards, Patrols or Management:

• Position:

• Direct Supervisor / Managers Name:

• Phone Number:

INCIDENT DETAILS

• Location at time of incident:

• Task at time of incident

• What happened unexpectedly:

• How did the incident happen:

• Did the incident involve injury to the body:

  Yes

  No

  N/A

• What Part/s of the body is/are affected?

• If injury was sustained, what kind of injury was suffered?

• Was equipment or property's involved?

  Yes

  No

  N/A

• What equipment or property was involved:

• Any other factors involved?

WITNESES

• Witness information:

Witness #

• Witness name:

• Witness Contact Number:

• Witness Signature:

  Sign

• If medical expenses are incurred, the supervisor is to ensure a workers compensation claim form is completed.

TREATMENT

• Was treatment by medical practitioner required?

  Yes

  No

  N/A

• If yes, please forward work cover medical certificate:

PREVENTION

• TO BE COMPLETED BY SUPERVISOR:

• What preventative actions can be taken:

• By Whom?

• What Date Was Above Preventative Action Taken:

• Supervisors Name:

• Supervisors Signature:

  Sign

OFFICE USE:

• Send completed form by Fax to Head Office 13 0030 3642. Or email to: callcentre@unitedpe.com.au

• Select Insurer:

  QBE Insurance

  GIO

• Date Insurer Notified:

  Date

• Report or Claim:

  Select Report Only Claim Only Report & Claim Following

  • Report Only
  • Claim Only
  • Report & Claim Following

• Person Notifying Insurer:

• Contact #

• Relationship to Injured Worker: (Return to work coordinator, OH&S Officer ect.)