Incident Notification Form

This form must be used to report any accidents (injury related event), incidents (non-injury related event) and near misses. Motor Vehicle Accidents (MVA) should be recorded on the MVA notification form.

Part 1 – Reported By
Part 2 – Incident Location
Part 3 – Incident Details

Describe the incident


  • The name of any process, chemicals or equipment used.

  • The contributing factors (e.g. brakes failed, floor wet due to rain, large volume of data entry).

  • The actions taken immediately (e.g. first aid provided.

Part 4 – Injured Person’s Details

(this Part must be completed if an injury/illness has occurred)

Injured Person’s Details

Injury Details

Treatment Details

Part 5 – Declaration
Draw signature|Type signatureClear
Part 6 - Manager's Acknowledgement

Investigation assigned to

*A copy of this form will be automatically sent to for record purposes.