Work Health and Safety Act: Incident Notification Form 3 - Queensland

This document is the Office of Industrial Relations Form 3, an incident notification form used in Queensland, Australia, under the Work Health and Safety Act 2011, Electrical Safety Act 2002, and Safety in Recreational Water Activities Act 2011. The form is designed to report various types of incidents, including deaths, serious injuries, dangerous events, and electrical incidents. It requires detailed information about the incident, including the date, time, and location; a description of the events leading to the incident; details of any persons involved; and information about the injured person's injury, illness, and treatment. The form also gathers information about the business or undertaking, including its legal and trading names, ABN, address, contact details, and main business activity. Furthermore, it asks about immediate and long-term actions taken to prevent recurrence. The document includes instructions on how to lodge the form, privacy statements, and contact information for further assistance. The form is a crucial tool for ensuring workplace safety and compliance with Queensland's regulatory requirements.

Office of Industrial Relations
Form 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 a
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 not
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 incidentPlease provide as much detail as possible, for instance: the events that led to the incident; the work being unde
the incident happened; the overall action, exposure or event that best describes the circumstances that resulted in the injury, illness, fatalit
incident; the object, substance or circumstance which was directly involved in inflicting the injury, illness, death or dangerous incident; the
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

2/3Form 3 Incident notification form ABN 94 496 188 983
Person’s injury/illness and treatment details(if required)
Mr Mrs Miss Ms First name: Last Name:
Date of birth: Contact phone number:
Residential address: Unit/Building No. Street No. Street Name
Suburb/Town/Locality State Postcode
Occupation:
(main duties)
Relationship to the entity notifying
Worker Self-employed Member of the public Labour hire worker Contractor
Group training apprentice/traineeOther(please specify):
Description of injury/illness:(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 following the injury/illness?
No Yes Please describe treatment received:
Where was the injured person
taken for treatment?
(if applicable)
Details of business or undertaking notifying of the incident
Legal name of business:
Trading name of business:
ABN: ACN:
Business address: Unit/Building No. Street No. Street Name
Suburb/Town/Locality State Postcode
Contact phone number: Work hours: Mobile:
Business email address:
Main business activity(e.g. furniture manufacture, domestic construction, steel warehousing, electrical installation)
Main industry sector
Accommodation and food services
Agriculture, forestry and fishing
Construction
Electricity, gas, water and waste services
Health care and social assistance
Manufacturing
Professional, scientific and technical
Rental, hiring and real estate services
Transport, postal and warehousing
Administrative and support services
Arts and recreational services
Education and training
Financial and insurance services
Information media and telecommuncations
Mining
Public administration and safety
Retail trade
Wholesale trade
Other services (please specify).

3/3
AEU1 18/5166© State of Queensland 2018
Form 3 Incident notification form ABN 94 496 188 983
worksafe.qld.gov.auOffice of Industrial Relations 1300 362 128
Describe any actions taken immediately following the incident to prevent recurrence:
Describe any longer term action proposed to prevent a recurrence:
Notifier’s details
Mr Mrs Miss Ms First name: Last Name:
Position at workplace: Contact phone number:
Email:
Is this the person that should be contacted for further information?
Yes No If no, please provide the name and contact details of the appropriate person should further information be
Mr Mrs Miss Ms First name: Last Name:
Position: Contact phone number:
How to lodge the form
Notification must be by fastest possible means.
The options for lodgement are by email to [e-mail] or by fax to [phone].
NOTE: Notification to Workplace Health and Safety Queensland or the Electrical Safety Office is not a notification to WorkCov
Call 1300 362 128 if you have any questions about filling out the form. Please keep a copy of this form for your own records b
PRIVACY STATEMENT: The Office of Industrial Relations respects your privacy and is committed to protecting your personal information. The information provided on this
Workplace Health and Safety Queensland and/or the Electrical Safety Office of a reportable incident under the Work Health and Safety Act 2011, Electrical Safety Regula
Water Activities Act 2011. This information will be managed within the requirements of the current state government privacy regime. Our office may be required to disc
other regulatory agencies such as the Queensland Police Service, WorkCover Queensland and other agencies in accordance with other law enforcement activities which
investigation. Further information on our privacy policy is available at www.worksafe.qld.gov.au/Privacy.