Who has been injured?

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

Declaration

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.

Please type what you see.

Further Information