Incident notification form

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: [email protected]
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:
Work number::
Postcode:
Mobile number:
Email Address:
Incident Details
Date of Incident:
Death of a person
Time of Incident: (am/pm)
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
Witnesses
Name of person(s) who saw the incident or was first on the scene
Details of Injured/Deceased Person(s)
Full Name:
Date of Birth:
Occupation/Job Title:
Direct Worker
Contractor
Member of public
Other
Address:
Suburb:
State:
Postcode:
Work number:
Mobile number:
Email:
Injury/Illness
Provide a description of any injury or illness
Did the person receive treatment following the injury/illness? If yes, describe treatment below
Yes
No
Action
Describe any Action taken/intended, if any, to prevent recurrence of the incident
Declaration
Date form
submitted:
Signed:
I have submitted this form electronically
(signature is not required)
2
Incident Notification Form (V2 March 2015)