Work Health and Safety Act 2011 Incident Notification Form - Office of Industrial Relations

Office of Industrial RelationsForm 3
Incident notification form
V4.11-2013
Work Health and Safety Act 2011
Safety in Recreational Water Activities Act 2011
Electrical Safety Act 2002
Incident details
Incident type
Please refer to the guide to work health and safety incident notification or electrical safety incident notification web page for assistance.
This is to notify of a: death serious injury serious illness dangerous incident serious electrical incident
dangerous electrical event
Provide an explanation of the type of incident using the categories on the guide to work health and safety incident notification or electrical
safety incident notification web page (e.g. a category of ‘serious injury’ is ‘immediate treatment for serious head injury’):
Incident date, time and location
Date of incident: Incident address:
Time of incident: Postcode:
Describe the specific location of the incident (e.g. aisle 3, plant operation room, tower crane the Elizabeth Street entrance side of the site.)
Description of the incident 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?
(Attach a separate piece of paper if necessary)
Did the incident involve licensed work (e.g. high risk work, electrical work?)
No Yes Please provide details of the type of licensed work:
Is the workplace a registered major hazard facility? No Yes