Incident Notification Form

Reference No. *

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

Full Name *

Phone Number *

Email *

Department *

Team

Your Manager's Name *

Your Manager's Email *

Part 2 – Incident Location

Airport *

Area *

Description of location *

Incident date and time *

Part 3 – Incident Details

Incident Type *

InjuryProperty damageEnvironmentalSecurity breachNear missOther

Incident severity *

Describe the incident

Include:

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.

Please attach photos or files (if appropriate)

Browse

Part 4 – Injured Person’s Details

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

Injured Person’s Details

First & last name

Phone number

Email address

Mobile number

Occupation category

ADG – StaffADG – ContractorADG TenantADG Tenant – ContractorAirline – StaffAirline – ContractorPAX/General PublicOther

Please specify *

Injury Details

Describe how the injury occurred

Nature of injury

Location of injury

Mechanism of injury

Agency of injury

Treatment Details

Treatment outcome

No TreatmentFirst Aid Incident (FAI)Medical Treatment Injury (MTI)Lost Time Injury (LTI)Fatality

Treatment provided by

Treatment provider name

Phone number

Treatment provider details

Part 5 – Declaration

I declare the information provided in this form is a true account of the incident. I acknowledge that ADG may need to disclose details of this report, including personal details, to relevant third parties. *

Signature of person listed in Part 1 *

Draw signature|Type signatureClear

Date

Part 6 - Manager's Acknowledgement

Investigation required? *

YesNo

Investigation assigned to

Name *

Email *

Title *

Phone number *

Comments/ Instructions *

*A copy of this form will be automatically sent to safety@adgnt.com.au for record purposes.

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