Accident / Incident Report
This is to notify one of the following:
Serious injury
Minor injury
Motor vehicle accident
Other
Other
Date of incident/accident
-
Day
-
Month
Year
Name of injured party
First Name
Last Name
Job title of 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)
Body location
(e.g. wrist, lower back, internal organs)
Did the person receive treatment?
Yes
No
Please describe treatment received (issued)
Where was the injured party taken to receive treatment?
(if applicable)
Was this incident reported to WorkCover QLD?
Yes
No
Unknown
WorkCover QLD Case number (if known)
Follow Up Action (if applicable)
Witness 1
First Name
Last Name
Witness 2
First Name
Last Name
Submit
Should be Empty: