Accident/incident Reporting Form - Act Government Page 2
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2Accident/Incident Reporting Form
Violence/Bullying/Harassment/Discrimination
Was Bullying/ Harassment
Was Discrimination
Was Violence/Abuse Involved?
Y / N
Y / N
Y / N
Involved?
Involved?
If ‘Yes’ to any of the above, please provide detail:
Background to Task
Task Being Performed:
(inc. lead up actions and specific
details of task.)
Experience in
Was appropriate Personal
Yrs:_____
Was Incident/Accident
Trained in
performing
Y / N
Protective Equipment
Y / N
Y / N
related to task?
task?
Mths:____
task?
required/worn?
Corrective Actions
Were any short term corrective
Y / N If ‘Yes’, please provide detail:
or preventative actions taken?
Are any long term preventative
Y / N If ‘Yes’, please provide detail:
actions required?
(inc. Training)
Witness
First Name:
Surname:
Position Title:
Preferred Contact Number:
Person Supervising at Time of Incident
First Name:
Surname:
Position Title:
Preferred Contact Number:
Form entered into RISKMAN by
First Name:
Surname:
Preferred contact number:
Position Title/Level:
Is this Incident/Accident a WorkSafe Notifiable Event? (please circle)
Y / N
Signature:
Date: ___ /___ /___
Privacy Notice:
The information in this form is collected to comply with the ACT Government's responsibilities for recording workplace
accidents/incidents and in accordance with Work Health and Safety Act 2011 as well as:
The Privacy Act 1988 (Cwth). The Privacy Act entitles you to check the record processed from the information you have
provided and to correct any inaccuracies.
The ACT Health Records (Privacy and Access) Act 1997 which outlines the rights of access to records and how they are kept.
The information in this form will only be disclosed to those who have authorisation to receive the information unless written permission
is obtained from the person involved.
Page 2
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