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Work Health & Safety Incident and Hazard Form

Please complete all fields on the form and click the Submit button. If you do not know any of the information, please enter Not Known or NA.

Required fields are marked with an asterisk (*).
Submitter details
Submitter details
You are reporting a
Incident (Near miss / no injury)

Name of person involved in the incident

Incident details

Date
Time
Incident (Resulting in an injury/illness)

Name of person involved in the incident

Incident details

Date
Time

Injury details

Injured person's supervisor details

Witnesses

Witness 1
Witness 2

Witness 3

Witness 4

Witness 5

Add another Witness

Notice

You have reached the maximum amount of witness' you can send per form.

Hazard

Hazard details

Date
Time
Security Incident

Security incident details

Date
Time

Privacy Acknowledgement: I acknowledge that information collected on this document is subject to the Privacy Act 1988 and is restricted to staff who may need this information in order to carry out their responsibilities. Information may be released to third parties such as WorkSafe ACT, Comcare, Rehabilitation Providers or other third parties as required.