Work Health and Safety (WHS) Incident Report Form
Your Full Name
*
First Name
Last Name
Incident | Injury Date
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-
Day
-
Month
Year
Incident | Injury Time
*
AM
PM
AM/PM Option
Host Employer Company Name
*
Type of Incident | Injury
*
Property Damage
Vehicle Damage
Injury
Hazard
Other
Injury | Incident Information (What, When, Where & How)
*
If Physical Injury | please select form the below
*
Head, Neck or Face
Back (lower, upper or mid)
Arm, Hand, Elbow, Wrist or Finger
Leg, knee, ankle or toe
Other
Have you called iStaff Australia to report the Incident | Injury?
*
YES, I have called iStaff Australia on 02 9525 8503, to report it.
NO, I will call iStaff Australia on 02 9525 8503, to report it.
Doctor Treatment
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I'm awaiting on instructions from iStaff Australia regarding a Doctors treatment
I have received a Doctors treatment
I do not require a Doctors treatment
Declaration
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I authorise the Company to act on my behalf regarding this injury Incident.
I agree with the Declaration and the Consent I have given.
I have completed this form truthfully and honestly.
I have called iStaff Australia and reported the Incident Injury over the phone.
By ticking all boxes, I confirm that I have completed the WHS Incident Injury Report Form accurately and honestly. I understand, if after completing this Form, the Company becomes aware that I have NOT been completely truthful in answering and completing the WHS Incident Injury Report Form, this will give the Company a right to take disciplinary action against me, including and not limited to the termination of my employment, if at that time I’m employed by the Company. I also understand that, it is my responsibility to report all work related WHS Incidents Injuries to the Company, immediately by calling the office emergency service on 02 9525 8503. By submitting this form I agree and give the Company authorisation to take all necessary steps involved in my recovery, return to work and injury incident investigation. This may include and not be limited to attending doctors appointments with me, discussions and correspondence with my treating doctor, rehabilitation provider, any other relevant professional to the treatment of the injury or persons involved in the process such as insurance providers or other relevant parties. Also I agree and authorise the Company to obtaining any relevant documents and forwarding those documents on to my treating doctor, other injury professionals, nominated insurance company and other relevant parties. I authorise and give this consent to the Company, to assist with my recovery, return to work and incident investigation. Also, I understand and agree that all information that the Company has obtained and collated, will be treated in confidence.
Submit
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