Incident / Accident Notification (Oct 2023) Type of Incident * Bullying & Harassment Motor Vehicle / Road Incident Discrimination Near Miss / Dangerous Occurrence Environmental Property Damage First Aid Injury Medical Treatment Injury Other Personal Details First name * Last name * Date of birth Contact phone number * Email Address * Employee number Occupation / Position at workplace Main duties. Employment type Casual Permanent Subcontractor Visitor Other Incident Details Date of incident * e.g. 12 August 2023 Time of incident * State * Select your StateNew South WalesVictoriaQueenslandWestern AustraliaSouth AustraliaTasmaniaAustralian Capital TerritoryNorthern TerritoryNew Zealand Client / Company Name where incident occurred * Company contact If known. Incident address * Describe specific location of incident e.g. Aisle 3, plant operation room, tower crane the Elizabeth Street entrance side of the site. What work was being performed at the time of this incident? Was this your normal work role / duty at this site? * Yes No If No, provide details here Description of incident - What happened? * Description of incident - How it happened? * Description of incident - Why it happened? * Was any plant or equipment being used at the time? * Yes No If Yes, what plant or equipment was it? Did the incident involve licenced work? Yes No If YES, please provide details of the type of licensed work Were there any witnesses to the incident? Yes No If Yes, please provide details (name, contact details, other) If the incident relates to bullying, harrassment or discrimination, what action would you like Labourforce to make? Are you injured as a result of this incident? * Yes No If Yes, type(s) of injury? Amputation Abrasion Bruise Burn Concussion Foreign body Fracture Laceration / cut Poisoning Sprain / strain Suspected internal injury Suspected spinal injury Other If Other, please detail If Yes, part of body injured? Arm - Left Arm - Right Chest - Left Chest - Right Shoulder - Left Shoulder - Right Back - Lower - Left Back - Lower - Right Back - Upper - Left Back - Upper - Right Neck - Left Neck - Right Foot / Ankle / Toes - Left Foot / Ankle / Toes - Right Hand / Wrist / Fingers - Left Hand / Wrist / Fingers - Right Stomach - Left Stomach - Right Face - Left Face - Right Head - Left Head - Right Knee / Leg - Left Knee / Leg - Right Other If Other, please detail Were you provided First Aid? Yes No Were Emergency Services notified? No Ambulance Police Fire Did you attend a doctor / GP? Yes No Name of doctor Did you attend a hospital? Yes No Name of hospital Were you admitted as an in-patient? Yes No What treatment has been given? All safety issues must be reported to the host employer. Have you reported this safety issue to your host employer? * Yes No If yes, who did you report to? Declaration: By submitting this form / report I declare that the information provided is correct to the best of my knowledge. Submit form If you are human, leave this field blank.
