Witness 1 Name
Witness 1 Phone

Witness 2 Name
Witness 2 Phone

Please call Emergency Services on '000' if needed.

Emergency Service Required —Please choose an option—NoneAmbulanceFirePoliceOther

This incident might need reporting to Workplace Health & Safety Queensland (WHSQ). You should get the Executive Director involved by urgently contacting Paul Barry on 0408 185 727. The notifiable incident report needs to be completed by the Executive Director.

Have you notified a RLSSQ Manager (or higher): —Please choose an option—YesNo

You have identified this incident as serious, you should notify the Executive Director Paul Barry on 0408 185 727 and let him know of the incident.

Personal Injury

Person Inured:
Person Phone:
Estimated Age:
Injury Type: —Please choose an option—Breathing EmergenciesCardiac ConditionsDislocationsElectrical injuriesFractures & Dislocations (broken bones, dislocations)Heath & Cold injuries (incl. Burns)Impact injury (incl. Bruises)Shock, fainting or anaphylaxisSoft Tissue InjuryTrauma Injury (bleeding, cuts, spinal, head, chest, etc)Poisoning, bites and stingsSprains and strainsOther

Damaged Equipment or Vehicle

Equipment damaged:
Location:
How was it damaged: —Please choose an option—Wear and TearMechanical failureElectrical failureFlooding or natural eventAccidental damage by customer / publicAccidental damage by staff / contractorEquipment damaged by being impacted by somethingOther
Describe Damage:
Is is fixed / repaired: —Please choose an option—YesYes, but only on a temporary basisNoOther
Is isolation required: —Please choose an option—Yes, I have isolated the equipmentYes, but I do not know / can not isolate the equipmentNoOther

Fire, chemical, environmental, fumes or toxic substance

Damage to Buildings

Other Incident