Incident Details (Must be completed for all Injuries / Incidents)

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Notifiable Incident Classification

Incident Notified To

OHS Regulator
(Refer To Section 35 Of The WHS Act For A Definition Of Notifiable Incident)

Reference Number

Contact Name

Date

Time

Was there more than one person injured / Involved?

Yes
(If Yes, Then Complete An Incident Investigation Report For Each Injured / Involved Person).