WHSIncidentForm

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Hazard / Incident / Accident Report & Investigation Form

This form is used to report an incident, accident or hazard at work (or on the way to/from work) and is to be filled in by the HTN Apprentice or Trainee. This form MUST be completed within 24 hours of any incident and should also be reported verbally to the relavant HTN Field Consultant by telephone (call 1300 139 108 and ask for your Field Consultant).

Hazard

Near Miss

Notification Only

Lost Time Injury

Medical Treatment Only

First Aid

Property Damage

Fatality

Motor Vehicle Accident

Person Effected *

Your Full Name *

Gender *

Date of Birth (dd/mm/yyyy) *

Preferred Language (if different than English)

Home Phone Number

Mobile Phone number

Your Email Address

Home Street Address *

Home Street Address 2

Home Suburb *

Home State *

Home Post Code *

Host Employer (Business Name) *

Position *

Apprentice / Trainee Year *

Incident Date *

Time of incident *

Reported date *

Time reported *

Name of the person the incident was reported to *

Location of the incident (address and location) *

Describe the incident *

Describe the injury in detail (are of body, type of injury, equipment damaged etc *

What caused the incident? eg: wet floor etc *

First Aid Only received?

Other medical treatment received?

Describe any medical treatment

Hospitalization?

Surgery

Other

Dr details (if known) Name

Dr phone number

Dr fax number

Dr address

Suitable for Work *

If unfit please note date ceased work

Were there any witnesses to the incident? *

If yes, please list names and contact details

Field Consultant Name *

Report Completed by: (name and position) *

Attach if any supporting files. Size limit for each file is 9.8 MB

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