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Incident Report
WorkSafe Victoria Aligned
Safety
If this is a medical emergency, call 000 first.
Complete this form after ensuring everyone is safe. WorkSafe Victoria:
13 23 60
1. Incident Details
Basic information about when and where the incident occurred.
Date
*
Time
Location / Address
*
Project (if applicable)
Not project-related
Not project-related
Incident Type
*
Injury
Illness
Near Miss
Property Damage
Environmental
Dangerous Occurrence
2. What Happened
Describe the incident in your own words. Include what you were doing, what went wrong, and any contributing factors.
Description
*
0 characters (minimum 10)
Immediate Actions Taken
3. Witnesses
Witness Names (if any)
4. WorkSafe Victoria Notification
Certain incidents must be reported to WorkSafe Victoria. Notifiable incidents include: death, serious injury requiring hospitalisation, or a dangerous incident that exposed a person to serious risk.
I believe this incident may be notifiable to WorkSafe Victoria (OHS Act 2004 s.38)
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