• Incident Reporting Form

    Incident Reporting Form

    Use this form to report any workplace accident, injury, incident and close call.

  • This form must be completed within 24 hours of an accident/incident or near miss occurring.

    STAFF ONLY - If lodging a Workers’ Compensation Claim you must contact the COO (coo@pia.edu.au) for a Workers’ Compensation Claim Form to be given to the worker’s nominated treating doctor to obtain a Work Cover Medical Certificate.

    STUDENTS ONLY - If lodging an insurance claim, further information is available from Student Support Officers.

    FOR ALL other incidents please complete the section of the report with as much detail as available.

    This report is CONFIDENTIAL, and the information provided is protected by:

    • NSW: The Privacy and Personal Information Protection Act 1998 (NSW)(PPIP Act), and the Health Records and the Information Privacy Act 2002 (NSW)(HRIP Act).
    • VIC: Privacy and Data Protection Act 2014 (Vic)(PDP Act) and the Health Records Act 2001 (Vic)

  • To help you answer the question below please be aware of these definitions:

    Critical Incident: A traumatic event, or the threat of such (within or outside Australia), which causes extreme stress, fear or injury.

    Sexual assault: When a person is forced, coerced or tricked into sexual contact against their will or without their consent,

    Sexual harassment: Is any unwelcome behaviour of a sexual nature that makes a person feel offended, humiliated or intimidated.  It can happen during face-to-face interaction, or online.

    WHS Incident: A situation or thing that has the potential to harm a person.

    Fraudulent Behaviour/Activity: Receiving a document perceived to be deliberately deceitful, dishonest, or untrue.

    IT/Cybersecurity: An unwanted or unexpected IT or cybersecurity event, or a series of such events, that has either compromised business operations or has a significant probability of compromising business operations.

    Data/Privacy Breach: Data released to the wrong person or persons or some other form of private information being compromised.

  • What type of incident it is?
  • Location
  • The Incident is for

  • Details of the affected person.

    To be completed by person/first aid officer/witness.
  • Gender
  • Date of birth
     - -
    2 digit day, 2 digit month, 4 digit year
  • Format: (000) 000-0000.
  • Is the affected person a:
  • Employment status
  • Date and time incident occurred
     - -
    2 digit day, 2 digit month, 4 digit year
  • Reported or visible symptoms of Injury:

  • Details of the affected system(s).

    To be completed by person/first aid officer/witness.

  • Witness/s details

    • Witness 1 
    • Format: (000) 000-0000.
    • Witness 2 
    • Format: (000) 000-0000.
    • Witness 3 
    • Format: (000) 000-0000.
    •  
    • Did you return to work or study?
    • As you have not returned to work/study, please enter the date you stopped:
       - -
      2 digit day, 2 digit month, 4 digit year
    • As you have returned to work/study, please enter the date you started:
       - -
      2 digit day, 2 digit month, 4 digit year
    • Was first aid provided?
    • Does the first aid kit need supplies added?
    • Did you visit a doctor about this incident?
    • Format: (000) 000-0000.
    • Did you attend a hospital about this incident?
    • Format: (000) 000-0000.

    • Investigation of Incident

    • The table will help you to identify the risk level:

       Risk level  Instances
      Severe
      (Emergency Services
      required)
      • Death, suicide or threat of suicide, or life-threatening injury;
      • Deprivation of liberty, threats of violence, assault, rape/sexual assault, aggravated
      • burglary, use of firearms, biological or chemical weapons;
      • Fire, bomb, explosion, gas/chemical hazards, discharge of firearms; or
      • Threat of widespread infection or contamination.
      Significant
      • Severe Occupational Health and Safety (OHS) risk
      • Serious injury incurred by staff member or student
      • Activity where evacuation is required
       Moderate
      • OHS risk
      • Suspicious package left unattended
      • IT system crashes
      • Student suffers epileptic fit
      Minor
      • Minor injury
      • Plumbing blockages
      • Phone/electrical failure
      • Computer breakdown
    • Type of fraud
    • Type of IT/cybersecurity incident
    • Type of hazard
    • Please select the department where fraudulent behaviour happened
    • Action taken to mitigate or control the hazard immediately
    • Date and time of action taken
       - -
      2 digit day, 2 digit month, 4 digit year
    • For Investigation purposes and to help to prevent similar occurrences in the future, do you consent to your designated Workplace Health and Safety Representative being provided with a copy of this accident report?
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    • Incidents involving a fatality or a serious injury or notifiable illness to staff, a visitor, volunteer, student or contractor

      Call Work Cover immediately on 13 10 50 as an urgent investigation may be needed

    • Data Breaches must be assessed in consultation with the Records Management, Security, Retention and Disposal Policy and Procedure.

    • Form completed by & signature

    • Format: (000) 000-0000.
  • Should be Empty: