subject_line
Accident Incident Report
Employee to complete Sections 1 and 2 and forward without delay in the event of any accident, incident or near miss.
IMPORTANT: Please consider whether the event you are reporting is one of the events below - if you are uncertain, please contact the Case Manager or Office to discuss.
VERY IMPORTANT: IF YOU HAVE CALLED AN AMBULANCE FOR A CLIENT / PARTICIPANT YOU MUST COMPLETE AN INCIDENT REPORT.
Please note: An ACCIDENT is an event where there has been an injury sustained and an INCIDENT is where an event has occurred and there has been no injury to the person and/or there may have been property damage. A NEAR MISS is where neither of above has occurred, but the event needs to be reported. A Hazard is a situation that could cause harm or injury.
Please choose which best describes the event
*
Accident
Incident
Near miss
Hazard
Section 1a - Employee Details Complete for all reportable instances
Completion of this form does not constitute an employee claim for Workers' Compensation. These forms are available in the office.
Employee's Name
*
Date occurred
*
+
Time Occurred
*
Employee Position
*
Support Worker
Office Employee
Case Coordinator
Case Manager
HR Team Member
Contractor
Volunteer
Section 1b - Client Details - Complete if required
Clients Name
Date occurred
+
Section 2 - Classification
Describe what happened - please include where, when, how, why & any actions taken.
*
Were there any injuries or damages?
*
No
Yes - details:
Yes - details:
Were there any witnesses?
*
No
Yes - Witness Name:
Yes - Witness Name:
Did you report this to the office?
*
No
Yes - reported to:
Yes - reported to:
Will you be making a Workers' Compensation or Volunteer Insurance Claim?
*
Unsure
Yes
No
If you will be making a claim - please advise the office within 24 hours & we will organise claim forms.
Employee Signature
*
clear
Date
*
+
Powered by
P:\FORMS AND POLICIES FOR COMMON CARE STANDARDS\Forms\WHS forms\Client Accident Incident Report revised 10032020 mh.docx