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Incident Report Form

Part A - Employee to Complete

Please complete the form below if you are the employee who was involved in the incident/accident.
Report Type(Required)

Person(s) involved

Name(Required)
DD slash MM slash YYYY
Employment Status(Required)

Incident Details

Injury details (if applicable)

Type of injury
Treatment

Supporting documentation

Max. file size: 50 MB.

 

 

Part B - Line Manager to Complete

Please complete the form below if you are the Line Manager of the employee or subcontractor involved in the incident/accident.

Investigation of Incident

Has training been provided relevant to the job being performed?(Required)
Was there a safe working procedure for this task?(Required)
If no, should one be provided?
Was any of the involved plant/equipment damaged, unguarded, due for service etc?(Required)
Was any of the involved plant/equipment damaged, unguarded, due for service etc?(Required)
Employee status(Required)

Insurance

The following information is required for Insurance Claims and is to be completed for all Reports.

Third Party Details (if applicable)

The following information is required where Non-Company Vehicles, Equipment or Personnel are involved causing injury or damage.

Your details

Name(Required)

 

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*Leederville Reception is closed on Thursday mornings.

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Midland WA 6056

T: (08) 9422 0700

Maintenance / Repairs: 1300 895 205

 

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Office Hours:
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T: (08) 9172 9700
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