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Select Page

Incident Report - QWALC Member Group

used to report incidences

"*" indicates required fields

Type of Incident:
Was treatment required required?*
Work Site Details
Project Address:*
Person Responsible for the Project or Activity Site*
First Name
Last Name
(eg: Volunteer team leader, contracted supervisor, other - be specific)
Incident Details
DD slash MM slash YYYY
Time of incident:*
:
Name of Injured Person:*
First Name
Last Name
Contact (phone or email)
Gender*
Role of the Injured:*
Was the location of accident/incident different to the address provided above:*
Location of accident/incident:*
Was there a witness/es:*
Witness/es details:*
First Name
Last Name
Contact (phone or email)
 
(if there was more than 1 witness use the + sign to the right of the last column to add another person's details)
DD slash MM slash YYYY
Did the injury relate to a pre-existing injury or medical condition?*
If ‘Yes’, was this condition/injury disclosed or previously known to the group?*
Was an appropriate entry recorded in your register of injuries/incedences?*
Authorised person submitting this report:*
*
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

This field is hidden when viewing the form
DD dash MM dash YYYY
This field is hidden when viewing the form
This field is hidden when viewing the form
Was a claim made through QWaLC's insurer?
This field is hidden when viewing the form
This field is hidden when viewing the form
DD slash MM slash YYYY
This field is hidden when viewing the form

Phone: 07 3096 0451

Email: info@qwalc.org.au

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0407 696 792​ |  info@qwalc.org.au

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