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
INCIDENT REPORT STUDENT/VISITOR
TO BE COMPLETED WITHIN
24 HOURS OF INCIDENT

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

 

SECTIONS 1 - 5 to be completed by the Injured Student / Visitor

SECTIONS 6 to be completed by the Occupational Health and Safety Unit

SECTION 1: Details of Injured/Ill Student/Visitor:
(a)

Surname:

................................................................................................................................................................................................
(b)

Given Names:

.................................................................................................................................................................................................
(c)

Address:

Street: .....................................................................................................................................................................................

City: ................................................................................ State:.................................................P/Code: ...............................
(d)

Phone:

Work: .....................................................................................................................................................................................

Home: .....................................................................................................................................................................................

Mobile:....................................................................................................................................................................................
SECTION 2: Injury/Illness Details
(a)

Type of injury (please tick where applicable)

Fracture/Dislocation

Skin Disorder

Damage to artificial aids

Burn/Scald

Contusion/Crush

Bite/Sting

Cut/Abrasion (First-aid only)

Poison

Strain/Sprain

Open Wound (Medical Treatment)

Amputation

Other...........................................
(b)

Bodily location of injury/illness:

.

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

...................................................................................................................................................................................................................................
SECTION 3: First-aid/Medical Treatment

If any First-aid and/or Medical treatment was required please state name and phone number of First-Aid /Medical attendant:
1.

Name:

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

Phone No:

.........................................................................................
2.

Name:

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

Phone No:

.........................................................................................
3.

Name:

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

Phone No:

.........................................................................................
SECTION 4: Details of Incident
(a)

Date of Incident:

__ / __ / __

Time of Incident:

..................................................................am/pm
(b)

Date incident reported:

__ / __ / __
(c)

Location of incident:

..........................................................................................................................................................................
(d)

Mechanism of the Injury/illness/dangerous occurrence. (please tick where applicable)


Slip, trip or fall

Body stress (exertion to muscles, tendons, ligaments & bone)

Mental Stress

Chemical or other substance exposure

Noise or Vibration

Hitting objects with part of the body

Struck by a moving object

Biological Exposure (germs, viruses & bacteria)
(e)

Brief description of incident:

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

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

....................................................................................................................................................................................................................................
(f)

If any witnesses plase state name and phone number


1.

Name:

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

Phone No:

..............................................................................
2.

Name:

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

Phone No:

..............................................................................
3.

Name:

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

Phone No:

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

Any further comments:

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

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

.......................................................................................................................................................................................................................................................
SECTION 5: Declaration

To be completed by the injured/ill student/visitor:


I ..................................................................................................................... hereby declare that the information provided in the foregoing statement is true and correct.

Signature:

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

Date:

__ / __ / __

Name:

.................................................................................................................................
(Please Print)




Occupational Health and Safety Unit
(to complete)

SECTION 6: Action
(g)

Action taken to prevent the incident from occurring in the future:

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

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

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

Signature:

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

Date:

__ / __ / __

Name:

.................................................................................................................................
(Please Print)