Accident/incident Reporting Form - Act Government
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1
2Accident/Incident Reporting Form
Person Completing this Form
First Name:
Surname:
Preferred contact number:
Position Title/Level:
Signature:
Date: ___ /___ /___
Person Affected
Status of Person Affected:
(please circle/provide detail)
ACT Government Employee
Volunteer Emergency Worker
Third Party:____________________
First Name:
Surname:
Relevant Agency:
Brigade/Unit:
Preferred Contact Number:
Gender:
Email Address:
When did it occur?
Date and Time of Event:
___:___am/pm
___ /___ /___
Duty Officer/Supervisor Name:
Date and Time Duty Officer Notified:
___:___am/pm
___ /___ /___
Where did it occur?
Where did the
Incident/Accident Occur?
(inc.
Map reference, street address etc)
Exact Location of the
Incident/Accident?
(Shed, Truck,
Fireground, Roof, etc)
What happened?
Summary of Incident/Accident:
(inc. details on the outcome of the
Incident/Accident)
Impact of Incident/Accident:
(at
Was this a near miss? ..................................................................
time of reporting)
No injury or illness, it was a hazardous situation? ......................
Minor injury or illness, no time was lost as a result? ..................
Less than one day of lost work? ..................................................
One day or more of lost work? ....................................................
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Parent category: Business