Description of Incident

  • Date of Incident

  • Time of Incident

  • Date Reported

  • Time Reported

  • Location of Incident

  • Detailed description of incident

Injured Person Details

  • Details of Injured Person

  • If injured person is a student, indicate, student type

  • Name of Injured Person

  • Business Unit of Injured Person

  • Employee/Student Number

  • Date of Birth

  • Contact Telephone Numbers

Injury Details

  • Nature of Injury

  • Nature of Disease

  • Bodily location of injury

Injury Treatment

  • Treatment provided to injured/ill person (mark all that apply)

  • If first aid treatment provided, provide details (inlcuding description of treatment, who provided treatment)

  • Transported to Doctor/Hospital

  • If transported to Doctor/Hospital, provide details of method of transport

  • If transported to Doctor/Hospital, provide details of location

  • Was this a lost-time injury (other than on the day of the incident)?

Reporting Details

  • Provide details of who injury, incident or near miss was reported to (include name, position and contact number)

  • Provide details of any witnesses to the injury, incident or near miss (include name and contact details for each)

  • Provide details of person in charge of team/area (include name, position and contact number)


  • Signature of Injured Person

  • Signature of Reporting Person

  • Signature of Manager

For Completion by Investigating Officer Only

  • Class A Incident (comprehensive investigation by H&S Investigator Definition: Serious injury - fatal or non-fatal Dangerous incident Work caused illness Serious electrial incident Action: immediately notify General Manager/CEO If applicable, notify WSHQ or ESO Investigate immediately

  • Class B Incident (investigation by H&S Investigator) Definition: Significant injury Significant near miss or issue Action: Investigate within 2 working days

  • Class C Incident (investigation by Manager) Definition: minor injury or incident minor near miss or issue Action: investigate within 3 working days

  • Class P Incident (investigation by HR Manager) Definition: Psychological-related incident/injury/issue Action: Notify HR team for investigation and management

Investigation Details

  • Mechanism of Injury

  • Agency of Injury

  • Work Related or Non-Work Related

Investigation Report

  • What was happening at the time of the incident/near miss?

  • What happened unexpectedly?

  • How did the incident/near miss occur?

  • What were the underlying factors which caused the incident, injury or near miss? (include contributing factors and root causes)

Corrective Actions

  • Include details of Corrective Actions Required to Prevent this Incident occurring again. Include: - control measure - timeframe for implementing control - accountable person/team for implementing control - any other comments

Investigation Sign-Off

  • investigating Officer Signature:

  • Work Unit Manager Signature:

  • WHS Co-ordinator Signature:

  • Executive Director, People, Culture & Communication signature (for Cat A, B & P incidents)

  • General Manager Signature (for Cat. A, B & P incidents)

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