Hazard Incident – Safety & Reporting

Hidden

Entry ID(Required)

Report Type(Required)

Indicate if you are reporting a Hazard or an Incident.

Date Time Location

Indicate the date and time the hazard or incident orccurred.

Incident Date (mm/dd//yyyy)(Required)

The date the incident occurred or the hazard was identified.

Incident Time(Required)

The time the incident occurred or the hazard was identified. 24 Hour Format.

Incident Site Location(Required)

The site or venue or general area the incident or hazard occurred.

Incident Exact Location(Required)

Describe the exact location where the incident or hazard ocurred.

Reporter

Record your details.

Reporter Name(Required)

Your full name.

Reporter Role(Required)

Your role.

Reporter Mobile(Required)

Your mobile phone number.

Reporter Email(Required)

Your email address.

Hazard Detail

Hazard Description(Required)

Describe the hazard and related information in detail.

Hazard Fix Status(Required)

Was the hazard fixed or resolved?

Hazard Fix Description(Required)

If the hazard was fixed or resolved, describe how and when the hazard was resolved.

Incident Detail

Incident Description(Required)

Describe the incident in detail.

Injured Person and Treatment

Record information about the injured person and their treatment even if it is a duplicate of the Reporter information.

Injured Name(Required)

The full ame of the injured person.

Injured Date of Birth (dd/mm/yyyy)(Required)

Date of birth of the injured person.

Injured Mobile Phone(Required)

The mobile phone of the injured person.

Injured Email(Required)

The email of the injured person.

Injured Role(Required)

The role of the injured person.

Treatment Person Name(Required)

The name of the medical practioner or person who treated the injured person.

Injury Position(Required)

Injury and Treatment Description(Required)

Detail the injury or disease, part of the body affected and the treatment type provided, the name and locatiof of the treatment centre and any other related information.

Supervisor

In the event of an incident or harzard a supervisor must be notified. Indcate who was the supervisor and how were they notified.

Supervisor Notified Name(Required)

The name of the supervisor notified.

Supervisor Notification Method(Required)

How your supervisor was notified.

Witness

Witness One Name

The full name of Witness One.

Witness One Mobile

The mobile phone of Witness One.

Witness Two Name

THe full name of Witness Two.

Witenss Two Mobile

The mobile phone of Witness Two.

Images

Image One

Accepted file types: jpg, gif, png, jpeg, heic, Max. file size: 10 MB.

Image Two

Accepted file types: jpg, gif, png, jpeg, heic, Max. file size: 10 MB.

Comments

This field is for validation purposes and should be left unchanged.