Notification of Incidents that occurred before 1 January 2012

Notification of an incident

Comcare is collecting the information on this form to aid the efficient processing and recording of an OHS incident. The information is being collected to assist Comcare to determine whether an incident is notifiable and /or whether an investigation is warranted and may also be used to perform other functions as required by the Occupational Health and Safety Act 1991 and associated Regulations.

The collection of the information is required under section 68 of the Occupational Health and Safety Act 1991 and Regulation 37B of the Occupational Health and Safety (Safety Arrangements) Regulations 1991.

Comcare may disclose, some or all of this information, to: Comcare’s legal advisers; State and Territory OHS Regulators; courts or tribunals, including coronial inquests and inquiries; and on request by other relevant regulatory or investigative agencies.

Who should complete this form?

Click on the questions marks more information for help when completing this form.

The fields marked * are mandatory.

1 Details of employer

* 
Australian Business Number (ABN): more information More information
* Street address:
* Town/suburb:
* State:

* Postcode:

2 Details of Incident:

* Date of incident:
* Time of incident:
:    24 hour
* Type of incident:
more information More information
   

* Did this incident occur at a Major Hazard Facility:
more information More information


Where did the incident occur?

* Describe the exact location:
more information More information

Street address (if applicable):
Town/suburb:
   
State:
Postcode:
Country:
* Describe the sequence of events leading to the incident, including what, if anything, may have gone wrong:
more informationexamples
   
* What activity was being performed when the incident occurred:
more informationexamples
   
* What if any, plant, vehicles, equipment, substances or things were involved in the incident:
more informationexamples
   

3. Details of persons killed, seriously injured or incapacitated


Note: You must include the names of all persons killed, suffering a serious personal injury or incapacitated.
Person 1:
Title:
First names:
Last name:
Telephone number:
Email address:
Is the person:
more information More information
Provide injury details:
more informationexamples

Details of any treatment received or needed:
more informationexamples

show fields Person 2 - click here if required
 
Person 2:
Title:
First name:
Last name:
Telephone number:
Email address:
Is the person:
Provide injury details:
more information More information
Details of any treatment received or needed:
more information More information
[Hide]


show fields Additional injured persons - click here if required

Additional injured persons:
Details of any other persons injured in the incident:
more information More information
[Hide]


4. Details of Persons involved in a dangerous occurrence

Note: This person may be contacted to provide additional information about this incident.

First name:
Last name:
Telephone number:

Email address:

5. Action or proposed action by employer to prevent a recurrence of a similar incident

* What action was taken immediately following the incident to prevent a recurrence:
more information More information
 
* Describe any longer term action taken or proposed to prevent a recurrence:
more information More information
Details of person responsible for implementing any longer term remedial action
Title:
First name:
Last name:
Telephone number:
Email address:

6 Details of person completing this form

*Title:
*First name:
*Last name:
*Designation:
*Telephone number:
*Email address:
show fields Contact person for further enquiries - click here if different from above
 
Details of contact person for further enquiries:
Title:
First name:
Last name:
Designation:
Telephone number
Email address:
[Hide]

 

You will be able to print a copy of your notification after submitting your form.