Hazard and Incident Reporting

First Name *

Last Name *

Mobile Number *

Email Address *

What would you like to do? *

Report a Hazard

Report an Incident

Raise a Safety Concern

Where was the hazard located? *

Please describe the hazard: *

Have you or someone else done anything to reduce or mitigate the risk of the hazard? *

Yes

No

Please describe what has been done to mitigate the risk of the hazard: *

Has the Hazard Been Reported to Someone? *

Yes

No

Who has the Hazard been Reported to? *

First Name *

Last Name *

Date of Birth *

Mobile *

Employment Status *

Employee

Volunteer

Attender / Participant / Member of Public

Date of Incident: *

Time of Incident: *

Location of Incident: *

Was the incident reported to anyone? *

Yes

No

Who was the incident reported to? *

Type of incident: *

Medical Treatment Injury

First Aid Injury

Near Miss

Other

Incident Description: *

Tip: Please describe what happened

Likely cause of incident *

Please specify other cause:

Did injury occur? *

Yes

No

Treatment Provided by: *

First Aider

Ambulance Officer

Other

Bodily Location: *

Tip: (eg. right wrist)

Treatment Provided: *

Treatment methods *

Treatment Refused? *

Yes

No

Ambulance Refused? *

Yes

No

Nature of Injury *

Please specify other nature of injury: *

Emergency Services Attended? *

Ambulance

Police

Fire

Time Called: *

Time Arrived: *

Report Number: *

Were there any Witnesses to this incident? *

Yes

No

First Name:

Last Name:

Contact Number:

First Name:

Last Name:

Contact Number:

Acknowledgement *

To the best of my knowledge the information given above is true and correct at the time of this report

Please describe your safety concern:

What could be done to resolve your concern?

Are you able to resolve the safety concern yourself?

Yes

No

Tip: Could you do something to fix the issue? e.g. put a sign-up encouraging drinking glass to be stored correctly

Your Details

Report a Hazard

Report an Incident

Details of person Injured or Involved in Incident

Details of Incident

Details of Injury

Other Details

Raise a Safety Concern