Macquarie University

Incident and Accident Report

Explanatory note: Use this form to report any work place incident involving injury/illness. Incidents involving death or significant injury/illness must be reported immediately to Human Resources.

Procedure: Injured employee or the person aware ofthe incident to complete the form.

PERSONAL DETAILS

Name of Person:
DOB:	/ /
Is the person:	University Employee Student Contractor Visitor
Occupation if NOT employed by the University:
Home address if NOT employed by the University:
Postcode if NOT employed by the University:

DETAILS OF INCIDENT/ACCIDENT

Date and Time of incident/accident	/ / :
Location:
Describe incident:
Type of injury:
Part of body injured:
Cause of injury:
Activity at time of injury:
Treatment details:	First Aid Doctor Hospital Refused Not required
Supervisor's Name
Was the Supervisor notified?	YesNo
If Yes, when: Must be after the "Date and Time of incident/accident"	/ / :
Time Lost from work?	YesNo
If Yes, no. of days
Please check if you have not returned to work yet

This report is CONFIDENTIAL and is protected by the Privacy and Personal Information Protection Act. This information will only be used for incident and injury prevention and data recording and analysis.