Incident notification form

Form to notify WorkSafe about an incident in the workplace.
Last updated

Mar 2022

Reading level


File type and size

PDF, 527.33 kB

Document length

3 pages

What it contains

This is a form to notify WorkSafe of incidents. It includes a telephone number to call for a reference number to prove they have notified WorkSafe immediately after the incident.

Important: Please download this PDF to your computer. You can fill it in using Adobe Reader but it will not save if you attempt to fill it in using your web browser.