Cartage Australia Pty Ltd
ABN 60 108 355 344
PO Box 879 Cranbourne Vic 3977
Tel: (03) 5996 1019 Fax: (03) 5996 6570

Injury/Incident Report

I am reporting a work related incident...

InjuryNear MissProperty Damage

Workplace Details

Workplace Address

35 Devon Road, Devon Meadows2 Fastline Road, TruganinaOther

Other Address *

Worker Details

Employee

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If your Employee Code is not yet in the system please manually add your details below.

First Name *

Last Name *

Email Address *For posting of your record of transaction.

Job Title *

Sex *

MaleFemale

Supervisor *

Supervisor Email

Other Supervisor *

Incident Details

Incident Date and Time *Date injury/near miss occurred or property damage identified.

Notification Date and Time *Date injury/near miss occurred or property damage reported.

Description of injury/near miss/property damage. *

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Please upload relevant injury/near miss/property damage pictures.

Exact location of worker at time of injury/near miss/property damage identified. *max. 255 characters.

Work activity being undertaken at time of incident. *Describe how the injury was sustained (or what injury may have been sustained if near miss); or what activity was being performed when the property damage was identified.

Was any equipment involved in the Incident? *

YesNo

If yes, please provide details... *

Was there a witness? *

YesNo

Witness Name *

Witness MobileNumbers only, no spaces, 10 digits in length.

Witness Email

Immediate action taken to prevent recurrence. *

First aid treatment received? *

YesNo

First Aider Name *

Medical treatment received? *

YesNo

Medical Clinic Name *

Worker Signature *

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Manager/Supervisor Review

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My Manager/Supervisor is unavailable to review this incident at this time, please email them a copy for them to review in my presence at a later time.

Reviewer

This incident has been reviewed in the presence of the Employee that made the incident report. *

Review Notes *

Review Actions *

Reviewed By *

Reviewed By Signature *

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Verify *