Incident Report Gravity Form | Queensland Water & Land Carers

Unique Report ID:

Member Group Name:*

Type of Incident:

Near miss

First aid case

Medical treatment case

Other significant event

Was treatment required required?*

Yes

Please describe the medical treatment that was required:*

Work Site Details

Project Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Person Responsible for the Project or Activity Site*

First Name

Last Name

Role*

(eg: Volunteer team leader, contracted supervisor, other - be specific)

Phone*

Email*

Incident Details

Date of incident:*

Time of incident:*

Name of Injured Person:*

First Name

Last Name

Contact (phone or email)

Gender*

Female

Male

Role of the Injured:*

Volunteer

Public Participant

Paid Staff

Describe in detail the type of injury/ies and body part/s affected:*

Was the location of accident/incident different to the address provided above:*

Yes

Location of accident/incident:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Was there a witness/es:*

Yes

List the task/s undertaken by injured party:*

Describe what safety instructions and/or training were given prior to project?*

What Personal Protective Equipment (PPE) was injured person wearing at time of the incident?*

Describe the incident/accident, identifying the cause:*

Detail the action(s) that has been taken at the work site level to prevent a recurrence?*

Date action(s) implemented:*

Did the injury relate to a pre-existing injury or medical condition?*

Yes

If ‘Yes’, was this condition/injury disclosed or previously known to the group?*

Yes

Was an appropriate entry recorded in your register of injuries/incedences?*

Yes

Detail further action/s recommended by project manager or responsible person:*

Authorised person submitting this report:*

First Last

Position in Group

Contact (phone or email)

Declaration and Submission

By clicking the 'Submit Incident Report' button below:

As the authorised person you declare that the details and information provided in this report are:

(i) true and correct and as a result
(ii) you understand that the details of the incident reported will recorded by QWaLC, and
may be used in the event of an insurance claim being made by your or any other parties involved.

Thank you for taking the time to complete this report.

The section below is only for use by QWaLC