HOW TO FILL OUT THIS FORM: (This form is for ALL hazards, incidents and accidents)
Note: This is not a WorkCover claim form
Person involved in incident or accident
NOTE: Reports containing confidential issues can be forwarded directly to OHSE, bypassing any party as necessary.
Person reporting environmental incident, hazard, fire or property damage
Health & Safety Representative
Occupational Health, Safety & Environment (OHSE)
E. Person Involved Details
F. Witness Details
Entered By Person - Person Involved to sign if completing form - otherwise by person completing this form.
Notice Acknowledged on Behalf of the Company (Designated manager to Sign)