Incident Notification Form
* NEW Dangerous Goods (Storage and Handling) Regulations 2012
On 1 December 2012, the Dangerous Goods (Storage and Handling) Regulations 2012 (DG (S&H) Regulations 2012) replaced the Dangerous Goods (Storage and Handling) Interim Regulations 2011 (Interim Regulations) which expired on this date. The DG (S&H) Regulations 2012 have retained most of the legal requirements contained in the Interim Regulations. There are only a small number of changes. This document has not yet been updated to reflect the changes introduced by the DG (S&H) Regulations 2012. More information on the key changes introduced by these new regulations can be found in the guidance titled Information about: Key changes to dangerous goods storage and handling requirements available at worksafe.vic.gov.au/dgkeychanges and More information about: Incident reporting available at worksafe.vic.gov.au/incidentreporting.
Incident Notification Form (PDF 149kb)
Document Type: Form
Category: Incident Notification New,
Publication Date: 02 December 2009
Date First Published: 11 October 2006
Summary: This form is used to notify WorkSafe of serious workplace incidents.
About this form
Section 38(3) of the Occupational Health and Safety Act 2004 and Regulation 904 of the Equipment (Public Safety) Regulations 2007 require an employer, self-employed person or a person in charge of ‘prescribed’ equipment to notify WorkSafe Victoria of a serious incident. Notification is required immediately (by telephone on 132 360) that the employer or self-employed person or person in charge of prescribed equipment becomes aware of a serious incident. Notification in writing is also required, within 48 hours of immediate notification, in a form approved by the Authority. This form is the approved form for written notification, which may be sent to WorkSafe Victoria by facsimile on (03) 9641 1091. For further guidance on what is a serious incident and notifiable to WorkSafe Victoria and how to notify, see the Guide to Incident Notification.
How to complete the form
If completing a hard copy form to be sent by facsimile, be sure to use an ink pen or ball point pen and print clearly. Remember to sign the declaration at the bottom of the form. The reverse side of the form provides basic information about notifiable incidents. Be sure to keep a copy of the completed form for your records.
If completing the editable PDF form, be sure to include your name and signature in the declaration section at the bottom of the form and to print and retain a copy for your records. Print and send to WorkSafe by facsimile to (03) 9641 1091.
Where to send the form
Send the form by facsimile to the Incident Notification Unit, Advisory Service, on Fax: 9641 1091. The form may also be sent by post to the Incident Notification Unit, Advisory Service, WorkSafe Victoria, 222 Exhibition Street, Melbourne 3000 or GPO Box 4306, Melbourne 3001.
If you want further information about this form or about incident notification, ring the Incident Notification Unit on 132 360.