Incident Notification Form
FORM 3 V1.11.02    Electrical Safety Act 2002, Workplace Health and Safety Act 1995
Please fill in the form then press the next button (* implies the field is mandatory). For help click
Incident Details
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 Type of event?     Dangerous Electrical Event Type:  
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 Type of incident:  
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 Was injury fatal?  
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 Incident date:  of       
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 Incident time:  :  
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 Incident description:
  Shop No:     Building:  
  Street No:     Street:  
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 Suburb:  
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 Post Code:     
  Incident location:
Details of Person Injured
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 Surname:  
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 First Name:  
  Other Names:  
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 Date of birth:  of       
  Shop No:     Building:  
  Street No:     Street:  
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 Suburb:  
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 Post Code:     
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 Gender     Occupation:  
  Employment type:  
  Employment basis:  
Injury Details
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 Nature of Illness/Injury:     Bodily location:  
  Medical treatment:     Hospital admitted to: (if overnight)  
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 Mechanisn of injury/illness:
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 Agency of injury/illness
Employer Details
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 Contractor/Employer name:     ABN:  
Submission
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 Notifier name:  
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 Notifier telephone no:  
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 Notifier Email Address:          
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.