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Incident Notification Form

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Incident Notification Form

Sections 35 to 39 of the Work Health and Safety (National Uniform Legislation) Act (WHS (NUL)Act) states NT

WorkSafe must be notified of the occurrence as soon as practicable by the PCBU on

1800 019

115. You will be

given an incident notification Reference Number that must be included on this form. This number is proof of your

notification phone call as soon as was practicable.

In addition to immediate (as soon as is practicable) phone notification, this 2-page notification form must be faxed or

emailed to NT WorkSafe within 48 hours after the incident occurrence. Fax: 08 8999 5141. Email:

ntworksafe@nt.gov.au

For more information please see NT WorkSafe bulletin Incident Notifications.

Incident Notification Form

Date:

Reference Number:

Person Submitting Details

(if completing form by hand, please print BLOCK letters)

Name:

Position Title:

Name of Employer/Self Employed Person notifying:

ABN:

Business address:

(Not Postal Address)

Suburb:

State:

Postcode:

Work number::

Mobile number:

Email Address:

Incident Details

Date of Incident:

Time of Incident: (am/pm)

Death of a person

Serious injury or illness

Dangerous incident

Name of Employer of any Injured or Deceased Person(s) if different from above: i.e.: subcontractor

ABN:

Address or location where the incident occurred:

Describe the specific location of the incident:

Work activity being undertaken at the time of the incident:

Provide a description of work being undertaken at the time of the incident including identifying any plant, substance and

equipment involved

Incident Notification Form

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