Accident / Incident Report
This is to notify one of the following:
Time of incident/accident
Date of incident/accident
Name of injured party
Job title of injured party
Name of person completing form (if not injured party)
Describe address and location of where Accident / Incident Occured
for example New Farm Confectionery 16 Waterloo Street, Newstead on the front deck of the retail shop
Describe the incident/accident
Please provide as much detail as possible, for instance: the events that led to the incident; the work being undertaken when the incident happened; the overall action, exposure or event that best describes the circumstances that resulted in the injury, illness, fatality or dangerous incident; the object, substance or circumstance which was directly involved in inflicting the injury, illness, death or dangerous incident; the name and type of any machinery, equipment or substance involved. Was anyone else involved? Was electricity or electrical equipment involved?
Description of the injury
(e.g. fracture, laceration, amputation, strain, electrical shock, burn, Q fever)
(e.g. wrist, lower back, internal organs)
Did the person receive treatment?
Please describe treatment received (issued)
Where was the injured party taken to receive treatment?
Was this incident reported to WorkCover QLD?
WorkCover QLD Case number (if known)
Follow Up Action (if applicable)
Should be Empty: