Employee Accident Incident Report

Support Worker to complete Sections 1 and 2 and forward without delay to the Case Manager in the event of any accident, incidsent or near miss.

Section 1 - Employee Details

Completion of this form does not constitute an employee claim for Workers' Compensation. These forms are available in the office.


Section 2 - Classification

Please chose which best describes the event *
Did you report the event to the Case Manager *
Receive medical attention? *
Will you be making a Workers' Compensation or Volunteer Insurance Claim? *

If you will be making a claim - please advise the office within 24 hours

Employee Signature *
Powered byFormsite
P:\FORMS AND POLICIES FOR COMMON CARE STANDARDS\Forms\WHS forms\Client Accident Incident Report revised 10032020 mh.docx