More about the online form
There are mandatory and optional fields in the online form.
Mandatory fields must be completed to be able to submit the report.
Optional fields are not mandatory but will assist in providing more details to the department.
Mandatory fields
Type of event
Choose from:
- electrical dangerous event
- serious electrical incident
- workplace health and safety incident (a serious bodily injury or work caused illness)
- workplace health and safety dangerous event
Type of incident
Choose from:
- death
- non-serious bodily injury
- serious bodily injury
- serious electrical incident
- work caused illness
Was the injury fatal?
Choose from:
- yes
- no
Incident date
Type in the day e.g. 05
Choose the month from the drop down selection e.g. Aug
The year defaults to the current year e.g. 2005
Incident time
Type in the time of the incident in 24 hour time e.g. 17:05
Incident description
This is free text where you should type in information about the incident and what happened.
Suburb
Type in the name of the suburb where the incident occurred
Postcode
Type in the postcode of the suburb where the incident occurred. There is a lookup function if you do not know the postcode of the suburb.
Details of person injured
Employers must keep records of each employee. These records are particularly important when completing the incident notification form, as personal information on the person injured is required to complete the form.
Surname
Type in the surname of the person injured in the incident
First name
Type in the first name of the person injured in the incident.
Date of birth
Type in the date of birth of the person injured in the incident.Type in the day e.g. 05
Choose the month from the drop down box e.g. Aug
The year defaults to the current year e.g. 2005
Suburb
Type in the name of the suburb where the incident occurred. There is a lookup function if you do not know the postcode of the suburb.
Gender
Select the gender of the person injured in the incident e.g. female or male
Injury details
Nature of illness/injury
Choose from one of the following choices in the drop down box:
- fracture
- sprain and strain
- burns
- abrasions
- amputation
- chemical burn
- splash in eye
- penetration by object
- back injury
- inhalation of substance
- ingestion of substance
- contusion
- electric shock
- internal injuries
- crush injuries
- decompression illness
- other diving injury
- concussion
- snorkelling injury
- medical condition
- psychological
- acoustic trauma
- dangerous event
Mechanism of injury of illness
Choose from the following options in the drop down box:
- falls, trips and slips
- hitting objects with part of body
- heat radiation and electricity
- sound and pressure
- body stressing
- chemicals and other substance
- biological factors
- mental stress
- other and unspecified mechanisms of injury
- being hit by moving objects
- workplace harassment
- occupational violence
- dangerous event
Agency of illness
Choose from the following options in the drop down box:
- machinery and (mainly) fixed plant
- powered equipment, tools and appliances
- chemicals and chemical products
- mobile plant and transport
- non-powered hand tools, appliances and equipment
- materials and substances
- animal, human and biological agencies
- environmental agencies
- other and unspecified agencies
- not determined during investigation
Employer details
Contractor/employer name
Type in the name of the principal contractor or employer in the format: first name last name e.g. John Smith
Submission
Notifier name
Type in the name of the person filling in the form, in the format: first name last name e.g. Marie Young
Notifier telephone number
Type in the contact telephone number for the person filling in the form.
Notifier email address
Type in the email address of the person filling in the form e.g. yourname@internetserviceprovider.com.au
Other fields that are not mandatory but will assist in providing more details to the Department of Employment and Industrial Relations include:
Optional fields
Incident details
- shop number
- building name
- street number
- street name
- incident location
Details of person injured
- other names
- shop number
- building name
- street number
- street
- occupation
- employment type - choose from one of the following:
- apprentice/trainee
- clerks
- electrical fitter
- electrical fitter mechanic
- electrical jointer
- electrical linesperson
- electrical mechanic
- labourers and related workers
- managers and administrators
- para-professionals
- plant and machine operators and drivers
- professionals
- restricted electrical licence holders
- salespersons and personal service workers
- tradespersons
- employment basis - choose from one of the following:
- casual
- electrical worker
- full time
- member of the public
- other
- part time
- self-employed
- supply electrical worker
- volunteer
Injury details
- bodily location
- medical treatment - choose from one of the following:
- CPR - performed
- doctor only
- first aid
- hospital - admitted
- hospital - observation
- medical treatment
- no medical treatment
- Hospital admitted to (if overnight)
Employer details
- ABN
Submitting the form
Once you are satisfied with the information you have provide, click on the 'Next' button. This will submit the form to the Department of Employment and Industrial Relations.
Fill in the incident notification form online
Print out a paper version of the incident notification form (PDF, 75kB) .
Last updated October 17, 2006
Other languages