Please provide your details as the referrer

* denotes a mandatory field required to complete the form

(if applicable)

please identify the nature of your enquiry

Please note anything not specifically covered by the fields above

Report an injury

If you or another employee have been injured complete a WHS Incident Report. If a client has been injured continue with the Clinical Incident Form.

Person Identifying & lodging clinical incident report

Incident Relating to Client

Incident Date & Time

9:30am or 0930 hrs

Incident Category

How is the incident defined?

Clinical Incident Details

Please provide details / facts surrounding the incident
Can you identify any contributing factors for this incident?
i.e. immediate actions taken to control risks present

Persons notified of Incident

Supporting Documentation


I have read and understood the privacy policy surrounding collection, storage and use of information submitted electronically. The information that I am submitting represents a true and correct reflection of the events. I understand that submitting a false statement may result in: 1. Complications in investigating this event. 2. Disciplinary action and possible termination of employment if submitting as an employee of the company.