WWCC - Near miss / incident / injury notification form

• Conducted on

  Date

• Prepared by

• Location
  Address

Details of person involved

• Name

• Address

• Date of Birth

  Date

• Phone number

• I identify my gender as

  Male

  Female

  Other

  Prefer not to disclose

• Division

• Position

  Select Employee Volunteer Contractor/Labour Hire Apprentice/Trainee Work Experience Member of Public

  • Employee
  • Volunteer
  • Contractor/Labour Hire
  • Apprentice/Trainee
  • Work Experience
  • Member of Public

Details of near miss / incident / injuries

• Type

  Incident

  Incident with injury

  Act of violence

  Near miss

• What happened? Describe what has occured

• How did it happen? Describe how this may have have happened.

• Immediate action? Were there any immediate actions taken to prevent this happening

• What happened? Describe what has occurred.

• How did this happen? Describe how this may have happened.

• Immediate action? Were there any immediate actions taken to prevent this happening.

• What happened? Describe what has occurred.

• How did it happen? Describe how this may have happened.

• Immediate action? Were there any immediate actions taken to prevent this happening.

• What happened? Describe what has occurred.

• How did it happen? Describe how this may have happened.

• Immediate action? Were there any immediate actions taken to prevent this happening.

• Location where incident happened
  Address

• Date incident happened

  Date

• Date incident reported

  Date

• Injury details. If an injury occurred, what part of the body was injured? (Eg cut to lift wrist; break to right leg; N/A etc)

First Aid / Medical Treatment

• Was first aid provided

  Yes

  No

  N/A

• First aid provided by

• Date

  Date

• Did the injured person stop work

  Yes

  No

  N/A

• Did the injured person attend medical care (eg doctor or hospital)

  Own doctor

  Hospital

  Other

• Name of Doctor / Medical Centre

• Name other type of medical care

Witnesses

• Were there any witnesses

  Yes

  No

  N/A

• Name of witness

• Phone number of witness

• Name of witness

• Phone number of witness

Signatures

• Sign here

  Sign