TO PRINT THIS FORM FROM THE POLICY LIBRARY, USE THE MS WORD LINK AT THE BOTTOM OF THE PAGE

 

Incident / Injury Report Form

Stop! Before completing this form the incident must be reported to a University supervisor to ensure area safety. If maintenance/repair is required please call 8888.

 

What should be reported?

§         Incident/accident

§         Injury, work caused illness and significant first aid treatment

§         Dangerous event or near miss (an incident which could have caused serious injury or extensive property damage but did not)

§         Property damage or hazardous activity observed.

 

If there has been a security breach or vehicle damage, use the following forms instead:

Security Incident Report Form in case of theft/suspicious person/event (Security Telephone: 7777)

Motor Vehicle Damage Report Form available from the Transport (Logistics) Office, Telephone: 387 57325.

 

What do you do with this form?

§         Save the Word document version of this form to your desktop, complete electronically and e-mail to relevant email address below

OR

§         Print the form, complete manually and send to relevant element H&S area below

 

Where do you work or study?	Address to send form
Student, or a staff member belonging to an Academic Group	Email: safety@griffith.edu.au Mail:  H&S Operational Unit, G05 1.11
Staff member in INS	Email: inssafe@griffith.edu.au Mail:  H&S Coordinator, N53 1.24
Staff member in Campus Life	Email: clfsafe@griffith.edu.au Mail:  H&S Coordinator, N11, 1.09
Staff member from non-academic areas, excluding INS & Campus Life	Email: stratsafe@griffith.edu.au Mail:  Strategic H&S, N54, 1.26

 

§         If incident only: sections A and D are compulsory.

§         If an injury has occurred: the entire form must be completed

For assistance in completing this form contact your Local Health & Safety Contact or Element Workplace Health and Safety Officer (WHSO) listed at

http://www.griffith.edu.au/hrm/health_and_safety/content_contacts.html

or contact the Health & Safety Operational Unit on 555 28366.

 

Griffith University collects, stores and uses personal information only for the purposes of administering workplace health & safety risk management. The information collected is confidential and will not be disclosed to third parties without your consent, except to meet government, legal or other regulatory authority requirements. For further information consult the University's Privacy Plan at www.griffith.edu.au/ua/aa/vc/pp

 

Office Use Only
Incident #:	Date Entered:
Injury #:	Entered by:
Incident Date:	Injured/Involved person:

 

 

Section A: Details of incident

Injury	Work related illness	Non work-related illness	Property damage
Dangerous event	Electrical incident	Environmental incident	Near miss

Name of person completing report:

Name:			Contact telephone:
Date incident occurred:			Time incident occurred:	am / pm

Incident occurred while:

At work	Travelling to/from work	On meal break	Other
Date reported:		Reported to:

Site of Incident:

Nathan	Gold Coast	South Bank	Off campus
Logan	Mt Gravatt	Student work placement

Exact location details: (external area / building & room etc)

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

What happened? (What were you doing at the time of the incident? Briefly describe how it happened.)

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Were any government agencies called to the incident? eg Police, Fire Services etc

 No  Yes (if yes provide details)

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

List any witnesses: (names, telephone contact details, ID No if applicable)

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..…………………………..

 

Section B: Details of injured person and injury

Family Name:		Given name/s:
Student/Staff ID:		M         F
Date of birth:		Telephone:
Position title:		School/Element:

Employment status:

Academic staff		General staff		College resident	Griffith student
Contractor*		Child		Visitor/member of public	Volunteer
Other:
* Name of contracting company:

Employment basis:

Full-time

Part-time

Casual

Name of injured person's supervisor:

……………………………………………………………………………………………………………………………………Details of treatment required:                                                                                            

None	Self	First aid **
Campus Medical Centre	Seen by other Medical Doctor	Hospital

**Describe first aid treatment given: ……………………………………………………………………………………………………………………………………Nature of injury:

Allergy or sensitivity			Exposure effects heat/cold		Occupational overuse injury
Amputation			Fainting		Poisoning/toxic effects
Asphyxiation			Foreign body		Post - traumatic shock
Bruising			Fracture/dislocation