Please send to:

The Occupational Health and Safety Unit
Level 2, T.C. Lamble Building
The University of New England
Armidale NSW 2351
THE UNIVERSITY OF NEW ENGLAND
DANGEROUS OCCURRENCE REPORT
TO BE COMPLETED WITHIN
12 HOURS OF INCIDENT

BEFORE COMPLETING THIS FORM:
YOU MUST CONTACT THE OCCUPATIONAL HEALTH AND SAFETY UNIT IMMEDIATELY

Contact:

Mr Bernard Wilkinson

Occupational Health and Safety Officer

6773 3232

Dr Mary Ditton

Injury Management Coordinator

6773 3433

Gail Creagan

Administrative Assistant

6773 3434

ENSURE A COPY OF THIS REPORT IS KEPT FOR YOUR RECORDS
BEFORE SENDING TO THE OCCUPATIONAL HEALTH AND SAFETY UNIT

All sections must be completed by the Supervisor responsible for the equipment involved:

SECTION 1:

Supervisors Name:

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Phone Number:

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Classification:

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Cost Centre:

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SECTION 2:

Description of Equipment:
(ie. plant, machinery, boiler, pressure vessel)

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Type of Equipment:
(ie. circular saw)

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SECTION 3:

Details of Incident:

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......................................................................................................................................................................................................

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......................................................................................................................................................................................................

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SECTION 4:

Any Staff members involved?

(Please circle one)

YES

NO

If YES

Goto Section 5

If NO

Goto Section 6


SECTION 5:

Was the Staff member injured?

(Please circle one)

YES

NO

If YES

Complete Injury/Illness Report

If NO

Goto Section 6

SECTION 6:

Details of Actions taken to correct:

.....................................................................................................................................................................................

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Signature:

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Date:

__ / __ / __