Workplace Health and Safety Incident Report Form
Incident Notification Form

FORM 3 V1.11.02    Electrical Safety Act 2002, Workplace Health and Safety Act 1995
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Incident Details
 * Type of event? Dangerous Electrical Event Type:
 * Type of incident:  * Was injury fatal?
 * Incident date:  of       * Incident time:  :
 * Incident description:
Shop No: Building:
Street No: Street:
 * Suburb:  * Post Code:   
Incident location:

Details of Person Injured
 * Surname:  * First Name:
Other Names:  * Date of birth:  of     
Shop No: Building:
Street No: Street:
 * Suburb:  * Post Code:   
 * Gender Occupation:
Employment type:
Employment basis:

Injury Details
 * Nature of Illness/Injury: Bodily location:
Medical treatment: Hospital admitted to: (if overnight)
 * Mechanisn of injury/illness:
 * Agency of injury/illness

Employer Details
 * Contractor/Employer name: ABN:

Submission
 * Notifier name:  * Notifier telephone no:
 * Notifier Email Address: