Incident Notification Form

 
  • Incident Notification Form (PDF 211kb)
    Document Type: Form
    Keycode: FOR537/12/09.13
    Industry: General, 
    Category: Incident Notification New, 
    Publication Date: October 2013
    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. 


Further information


If you want further information about this form or about incident notification, ring the Incident Notification Unit on 132 360.