Human Resources Work Health & Safety Incident Report Form PART A Details of the incident – Details of the person Name: completing the report Contact number: address: Branch/Business Unit: Division: □Justice □Office □Office Services of the Public Guardian of the Public Advocate □Youth □Strategic □Corporate Justice Services Policy and Legal Services Services □Liquor, Gaming and Fair Trading □Office □Ethical □Internal of the Director General Standards Audit □Child □Crown □Office Safety Director Law of the Director of Public Prosecutions □Other _____________________________ Independent Statutory Authority: _________________________________________________ Queensland Corrective Services incidents are reported in the system. N.B. SHE ______:________ am/pm on ____/____/____ Time and date of incident Location of incident Activity being undertaken Brief description of incident / near miss Names and contact details for witnesses to the incident □No □Yes Was anyone injured (skip to Part C) (complete Part B for each injured person) How many: ______ Signature: ____________________________ Date: ___ / ___ / _____ Submitted to: ____________________________ ___________________________ on (Name) (Position) N.B. This form is to be treated as Please retain the original and forward a copy to: for “CONFIDENTIAL”. central recording and reporting.
Human Resources Work Health & Safety Incident Report Form PART A – Details of the incident Details of the person completing the report Name: Contact number: address: Branch/Business Unit: Division: □Justice Services □Office of the Public Guardian □Office of the Public Advocate □Youth Justice Services □Strategic Policy and Legal Services □Corporate Services □Liquor, Gaming and Fair Trading □Office of the Director General □Ethical Standards □Internal Audit □Child Safety Director □Crown Law □Office of the Director of Public Prosecutions □Other _____________________________ Independent Statutory Authority: _________________________________________________ N.B. Queensland Corrective Services incidents are reported in the SHE system. Time and date of incident ______:________ am/pm on ____/____/____ Location of incident Activity being undertaken Brief description of incident / near miss Names and contact details for witnesses to the incident Was anyone injured □No (skip to Part C) □Yes (complete Part B for each injured person) How many: ______ Signature: ____________________________ Date: ___ / ___ / _____ Submitted to: ____________________________ ___________________________ on (Name) (Position) N.B. This form is to be treated as “CONFIDENTIAL”. Please retain the original and forward a copy to: for central recording and reporting.
incident-report-form-wh-and-s.docx