CELLINI | Incident Reporting

CELLINI | Incident Reporting

Welcome to the Comply Online Health & Safety Incident Reporting Module.
Please make sure that you complete all the required documentation to register your incident.

Introduction to the Incident Reporting Module
1. Your Name (The Investigator)

First NameSurname
2. Date Incident Took Place

MonthDayYear
Date
3. Time Incident Took Place

Hour Minutes

AM/PM Option
5. Select Branch
7. Are you reporting an incident that only involves damage, loss or theft of property, vehicles, or other assets (and not personal injury)?
If yes, download and complete the Notifiable Incident Report (NIR) form and inform finance of the incident so they can impair and/or write off the asset(s) and institute an insurance claim, if relevant.
8. Are you reporting an Incident that involves Personal Injury?
9. Who of the following people incurred personal Injury? IMPORTANT: Do not pay any medical bills on behalf of the injured visitor or contractor
10. Which type of incident are you reporting?
First Aid Case: NIR and First Aid Report Forms

Accident requiring Medical Attention: NIR, First Aid Report, WCL2 and Annexure 1 Forms.

Fatality: NIR, First Aid Report, WCL2 and Annexure 1 Forms.
11. Please upload the completed WCL2 and Annexure 1 documents (if you do not have a scanner available, take a photo of form and send through to HR at Head Office)

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12. Name of the Person affected

First NameLast Name
13. Which Part of the Body has been affected?
14. What is the Effect on the injured Person?
15. What is the expected period of disablement?
16. Describe activities leading to incident (e.g. tasks being performed at time of incident)
17. Please enter a brief description of the incident
18. Has any other staff been affected by the incident? Please add details
19. What was the root cause of the incident?
20. What steps will be taken to prevent this in future?
21. Please provide the name(s) of the most senior manager(s) who were informed of this incident.
22. If a witness was present, please enter their name

First NameLast Name
23. Please enter the phone number (mobile and work) of the witness
Please enter a valid phone number.Format: (000) 000-0000.
24. Your phone number
Please enter a valid phone number.Format: (000) 000-0000.
25. Your email address
example@example.com
Should be Empty: