VTC - Incident Notification Report
MSF-212-001V4
Division
Traffic
Depot
*
Please Select
Gold Coast Depot
Gympie Depot
Brisbane North Depot
Brisbane South Depot
Brisbane City Council Depot
Ipswich Depot
Toowoomba Depot
Sunshine Coast Depot
Bundaberg Depot
Mackay Depot
Rockhampton Depot
Report Completed By
*
Name of Client
Was the client Informed?
Yes
No
Type of Incident
*
Critical Incident
Lost Time Injury
First Aid Injury
Restricted Work Injury
Medical Treatment Injury
Motor Vehicle Incident
Property Damage
Near Miss
Environmental Incident
Other
Date of Incident
*
-
Day
-
Month
Year
Date
Time
*
Hour Minutes
Date Reported
*
-
Day
-
Month
Year
Date
Work Related
*
Yes
No
Incident Location
*
Was the Incident Witnessed?
*
Yes
No
Incident Summary
*
Incident Detailed Description
*
Immediate Corrective Action
*
Job Task
*
Job Task Location
*
Weather
*
Clear
Cloudy
Fog
Hazy
Hot
Ice
Inside
Overcast
Partly Cloudy
Rain
Sunny
Windy
Lighting
*
Dark
Dark – Artificial Light
Dawn/Dusk
Inside - Artificial
Inside – Natural Light
Natural
Proper PPE Used
*
Yes
No
N/A
Self-Supervised Activity
*
Yes
No
INJURY OR ILLNESS
Name
Person Type
Employee
Contractor
Public
Job Position
Time on Job
Hour Minutes
Nature of Injury/Illness
Amputation
Bruise, Contusion
Burn Chemical
Burn – Chemical or Thermal
Concussion
Crush
Cuts, Scrapes & Punctures
Dislocation
Foreign Object In eye
Fracture
Irritation
Sprain & Strain
Sting, Bite
Unknown, Uncertain In dispute
Airborne Diseases
Heat Stress, Exhaustion, Sunstroke
Other
Injured Body Part Photo
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Highest Medical Responder
Doctor
Emergency
First Aider
Self Treatment
Other
MOTOR VEHICLE INCIDENT
Vehicle 1
Make
Model
Type
Rego
Year
Colour
Drivers Name
Contact Number
License Number
License Expiry
-
Day
-
Month
Year
Date
Was Car Towed?
Please Select
Yes
No
Towing Company Name
Has the Driver consumed any drugs, alcohol or medication 12 hours prior to the incident? If Yes, please provide detail
Vehicle 2
Make
Model
Type
Rego
Year
Colour
Drivers Name
Contact Number
License Number
License Expiry
-
Day
-
Month
Year
Date
Was Car Towed?
Please Select
Yes
No
Towing Company Name
Has the Driver consumed any drugs, alcohol or medication 12 hours prior to the incident? If Yes, please provide detail
Damage Photos
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Incident overview
Please provide details of accident / incident and other relevant information
Other Parties Involved
Police at the scene
Ambulance at the scene
Other
Police Report Number
Comments
Comments in relation to other parties involved
WITNESS DETAILS
Witness 1
Name
Address
Phone
Email
example@example.com
Witness Type
Site Worker
Other Motorist
Member of Public
Other
Witness 2
Name
Address
Phone
Email
example@example.com
Witness Type
Site Worker
Other Motorist
Member of Public
Other
OTHER ASSOCIATED INFO AND PHOTOS
Other Information
Please enter any additional information
Additional Files
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Signed by
*
Signature
*
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