Incident Reporting Form

Incident Reporting Form

Use this form to report any workplace accident, injury, incident and close call.
This form must be completed within 24 hours of an accident/incident or near miss occurring.

STAFF ONLY - If lodging a Workers’ Compensation Claim you must contact the COO (coo@pia.edu.au) for a Workers’ Compensation Claim Form to be given to the worker’s nominated treating doctor to obtain a Work Cover Medical Certificate.

STUDENTS ONLY - If lodging an insurance claim, further information is available from Student Support Officers.

FOR ALL other incidents please complete the section of the report with as much detail as available.

This report is CONFIDENTIAL, and the information provided is protected by:
- NSW: The Privacy and Personal Information Protection Act 1998 (NSW)(PPIP Act), and the Health Records and the Information Privacy Act 2002 (NSW)(HRIP Act).
- VIC: Privacy and Data Protection Act 2014 (Vic)(PDP Act) and the Health Records Act 2001 (Vic)
To help you answer the question below please be aware of these definitions:

Critical Incident: A traumatic event, or the threat of such (within or outside Australia), which causes extreme stress, fear or injury.

Sexual assault: When a person is forced, coerced or tricked into sexual contact against their will or without their consent,

Sexual harassment: Is any unwelcome behaviour of a sexual nature that makes a person feel offended, humiliated or intimidated. It can happen during face-to-face interaction, or online.

WHS Hazard: A situation or thing that has the potential to harm a person.

Fraudulent Behaviour/Activity: Receiving a document perceived to be deliberately deceitful, dishonest, or untrue.

IT/Cybersecurity: An unwanted or unexpected IT or cybersecurity event, or a series of such events, that has either compromised business operations or has a significant probability of compromising business operations.

Data/Privacy Breach: Data released to the wrong person or persons or some other form of private information being compromised.
What type of incident it is?

Critical IncidentSexual Harassment or Sexual AssaultWHS HazardFraudulent Behavior/ActivityIT/Cybersecurity IncidentData/Privacy Breach
The Incident is for

an Individuala Group
Please provide details of the affected group below
Details of the affected person.

To be completed by person/first aid officer/witness.
Full name

First NameLast Name
Gender

MaleFemaleI prefer not to say.
Date of birth

DayMonthYear
Date
Phone number
Please enter a valid phone number.
Residential address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the affected person a:

Staff MemberStudentVisitor
Location

Sydney CampusGeelong CampusMelbourne Campus
Position title
Student services, Lecturer, Dean, ...
Employment status

Full TimePart TimeCasual
Date and time incident occurred

DayMonthYear
Date
Hour MinutesAM/PM Option
Number of hours worked before the incident on the day:
Nature of incident (Eg: Laceration, Sprain, near miss, Vehicle accident)
Area of Damage/Part of Body Injured (Eg: Right leg, Left hand, none)
Reported or visible symptoms of Injury:

BlistersBlood NoseBurnCardiac problemCutElectrical ShockFracture/BreakHeavy BleedingInfectionLoss of ConsciousnessOpen woundPoisoningStrainGrazePainTendernessInsect BiteOther
State exactly how the incident occurred:
Details of the affected system(s).

To be completed by person/first aid officer/witness.
What systems are affected and how?
Witness/s details
Witness/s

Risk level	Instances
Severe (Emergency Services required)	Death, suicide or threat of suicide, or life-threatening injury; Deprivation of liberty, threats of violence, assault, rape/sexual assault, aggravated burglary, use of firearms, biological or chemical weapons; Fire, bomb, explosion, gas/chemical hazards, discharge of firearms; or Threat of widespread infection or contamination.
Significant	Severe Occupational Health and Safety (OHS) risk Serious injury incurred by staff member or student Activity where evacuation is required
Moderate	OHS risk Suspicious package left unattended IT system crashes Student suffers epileptic fit
Minor	Minor injury Plumbing blockages Phone/electrical failure Computer breakdown

Incident Reporting Form

Details of the affected person.

Details of the affected system(s).

Witness/s details

Investigation of Incident

Incidents involving a fatality or a serious injury or notifiable illness to staff, a visitor, volunteer, student or contractor

Data Breaches must be assessed in consultation with the Records Management, Security, Retention and Disposal Policy and Procedure.

Form completed by & signature