HEALTH AND SAFETY AT WORK (ADMINISTRATION) REGULATIONS 1997

A. About the employer or person in control

• 1.Registered name of the company________________
• 2.Trading name________________
• 3.Address of the registered office________________ ________________ ________________
• 4.Address of the workplace or where accident/occurrence took place________________ ________________ ________________
• 5.Main activity carried out at the workplace________________
• 6.Number of people employed at the workplace or site________________
• 7.Is there a OHS committee at the workplace or site Yes/No

B. About the injured or ill person

• 8.Surname ________ Given names ________
• 9.Sex (M or F) ________ 10. Date of birth________
• 11.Is the injured or ill person an employee of the above company Yes/No If no, go to section 16

BASIS OF EMPLOYMENT

• 12.Shift Arrangement 1.__ Fixed, standard or flexible hours

  2.__ Rotating Shift

• 13.Number of hours  1.__ 8 hours or less

  2.__ more than 8 hours (excluding overtime)

• 14.JOB DETAILS

  Description of occupation or job title________________

  Main tasks performed________________

• 15.Training provided 1.__ Induction training 2.__ Task specific training

  3.__ Both of the above 4.  __ Neither of the above

DETAILS OF THE INJURY OR DISEASE

(Refer to Schedules 5 and 6)

• 16.Date injury occurred Day Month Year

  or disease report__ /__ /__

• 17.Time of injury or disease____ /____
• 18.Nature of injury or disease________________
• 19.Bodily location of injury or disease________________
• 20.Description of occurrence of injury or disease:
  • •In which part of the workplace did the injury or disease exposure occur? (eg machine, shop, freezer room)

    ________________

    ________________

  • •What was the person doing at the time? (eg driving a fork lift truck, lifting bags of cement, typing)

    ________________

    ________________

  • •What happened unexpectedly?

    Include the name of any particular chemical, product, process or equipment involved (eg brakes failed on fork lift truck, slipped on wet floor, scaffolding collapsed, arm started hurting while typing on a word processor.

    ________________

    ________________

    ________________

  • •How was the injury or disease sustained?

    Include the time of any chemical, product process or equipment involved. (eg hit head on cabin of fork lift truck, lacerated knee when landing on ground, arm hurt after long period of typing)

    ________________

    ________________

    ________________

LOST-TIME INJURY/DISEASE

Additional questions to be answered for cases which result in fatality or permanent disability, or where there time lost from work of one or more day/shifts. These questions should be completed as soon as possible after the injury or disease is reported.

• 21.Employee’s preferred language________________
• 22.Type of employment:____ Full-time____ Part-time____ Casual
• 23.Type of employee:

  Wage/Salary earner__ Trainee __ Outworker__ Apprentice

        __ Pieceworker__ Other

  Self employed:__ (including contractors and subcontractors)

  Unpaid worker__ Work experience____________

• 24.Worker’s experience in task being carried out when Years Month injury or disease occurred __ /__

Details of person completing this form

Name: ________ Position:________

Signature:________ Date:________

OUTCOME OF INJURY/DISEASES

Questions 25–29 are about information that is not available at the time of the report of injury or disease. These questions should be answered as soon as the information becomes available. For some occurrences, questions will not be relevant.

• 25.Rehabilitation 1__ Required Day Month Year    /   /

   2__ Not required

• 26.Was the outcome injury or disease 1.__   2.__
• 27.Preventive action proposed or taken:

  ________________

  ________________

• 28.Date of Resumption of work on: Day Month Year __ /__ /__
• 29.Total number of working days lost ________

Employer to retain a copy of this Notification Form.