DATE:
REQUEST#:
Name:
Surname:
Email:
Contact Number:
Department: Please selectT+ET+E WarehouseStoneStone WarehouseService / MachineryService WarehouseAdmin
Please selectInjury – First AidInjury – Medical / Emergency TreatmentProperty DamageEquipment FailureMotor VehicleIncident without injury/near missOther
Note: Please take photos where possible and attach them at the bottom of this form
Other Party's Name:
Other Party's Driver Licence:
Other Party's Rego Number:
Other Party's Insurance Details:
Date of Incident:
Time of Incident:
Site: Please select4 Freighter Road, VIC1 Freighter Road, VIC4 Simpson Street, VICRichmond ShowroomMoorebankAlexandriaGold CoastMalagaHindmarshOther
Describe Incident:
Any witness statements taken? YesNo
First Name
Surename
Contact No
Photographs taken and attached to report? YesNo
Description includes all relevant details? YesNo
Hazard Resolved or isolated? ResolvedIsolated
Has the HSR been notified? YesNo
Has the Management OHS representative been notified? YesNo
What is the resolution?
Please attach any supporting evidence:
If an injury occurred, the Register of Injuries Form will need to be completed and attached when submitting the incident report.
CDKNat OHS 015F-1 Register of Injuries Form.pdf
Motor Vehicle Accident Report form.pdf
