Name Contact Phone Number*Email Address* Business or Company representing* Time and date of incidentTime : Hours Minutes AM PM Date DD slash MM slash YYYY Exact site location where injury occurred* Incident Type*Please SelectInjuryIncident/Near MissHazardMotor Vehicle AccidentCriminal ActActivity in which the person was engaged at the time of injuryBrief description of incident or near missNames of witnesses to the incident Contact details of witnesses to the incidentWas anyone injured? Yes No How Many? Details of injured personName Gender Male Female Date of Birth MM slash DD slash YYYY Contact DetailsWork PhoneHome PhoneMobileEmail Address Relationship with QSSS QSSS Employee Contractor Visitor Other Enter more detail QSSS Employee DetailsPosition Title Type of Employment Full time Part time Casual Will a WorkCover claim be lodged? Yes No Unsure Work cycle Journey Meal break Work site Mechanism of Injury Slip/ trip/ fall Manual handling Body stressing Being hit by falling object Hitting an object/s with part of the body Being hit by moving objects Exposure to heat / radiation / electricity Exposure to biological agent Exposure to Chemical agent Exposure to asbestos Exposure to work stress Violence Other inappropriate behaviour Other (indicate all relevant)Enter brief explanation here Nature of Injury Sprain / Strain Fracture Bruising Cuts / Scratch / Abrasion Burn Bite/Sting Electrical shock Concussion Psychological Other (indicate all relevant)Site of injury on the Body Head Neck Shoulder Arms Hands Fingers Body Leg Foot Others Please specify Enter brief explanation hereSignatureEmailThis field is for validation purposes and should be left unchanged.