Electricity Entity Incident Form

Form 1 V2.03-2006      Electrical Safety Act 2002 Note: Reporting a serious electrical incident or a dangerous electrical event is not an admission of liability by the electricity entity in respect to that incident or event. Please fill in the form then press the next button (* implies the field is mandatory). For help click

Notifier Details

* Notifier name:   * Notifier telephone no:   * Notifier email address:

Submission

The Department of Industrial Relations respects your privacy and is committed to protecting personal information. The information provided on this form is for the purpose of advising Workplace Health and Safety Queensland and/or the Electrical Safety Office of a reportable incident and will be managed within the requirements of Information Standard 42, Workplace Health and Safety Regulation 1997 and Electrical Safety Regulation 2002. For reasons of health and safety the Department may be required to disclose the personal information contained in this form to other government agencies or entities, or as may be required by law. Further information on our privacy policy is available on our web site.