Incident notification

A workplace or electrical safety incident that falls into one of the below categories is required to be notified to the Office of Industrial Relations Queensland under the Work Health and Safety Act 2011, the Safety in Recreational Water Activities Act 2011, or the Electrical Safety Act 2002.

Use this form to notify Workplace Health and Safety Queensland or the Electrical Safety Office of an incident, select the item below that best describes the incident outcome and click 'Next'. If a worker has been injured, you can also make a claim with WorkCover Queensland using this form.

The death of a person other than by electricity

Important Notice
Please confirm the following:

  • I acknowledge that the scene of the notifiable incident must be preserved.
  • If you are reporting a fatality or a serious injury/illness requiring hospitalisation after normal work hours - please also phone 1300 362 128 to notify WHSQ on-call manager.

Work hours: Monday 8am - Friday 5pm.
After work hours: Friday 5pm - Monday 8am and Queensland Government public holidays.

An injury or illness requiring a person to have immediate treatment as an in-patient in a hospital

Important Notice
Please confirm the following:

  • I acknowledge that the scene of the notifiable incident must be preserved.
  • If you are reporting a fatality or a serious injury/illness requiring hospitalisation after normal work hours - please also phone 1300 362 128 to notify WHSQ on-call manager.

Work hours: Monday 8am - Friday 5pm.
After work hours: Friday 5pm - Monday 8am and Queensland Government public holidays.

A serious injury or illness requiring a person to have any of the following ...

  • Immediate treatment for the amputation of any part of his or her body
  • Immediate treatment for a serious head injury
  • Immediate treatment for a serious eye injury
  • Immediate treatment for a serious burn
  • Immediate treatment for the separation of skin from an underlying tissue
  • Immediate treatment for a spinal injury
  • Immediate treatment for the loss of a bodily function
  • Immediate treatment for a serious laceration
  • Medical treatment within 48hrs of exposure to a substance

An infection to which the carrying out of work was a significant contributing factor

An infection reliably attributable to carrying out work ...

  • With micro-organisms
  • That involved providing treatment to a person
  • That involved contact with human blood or body substances
  • That involved handling or contact with animals, animal hides, skins, wool or hair, animal carcasses or animal waste products

contraction of the following zoonoses in the course of work involving handling or contact with animals, animal hides, skins, wool or hair, animal carcasses or animal waste products: ...

  • Q fever
  • Anthrax
  • Leptospirosis
  • Brucellosis
  • Hendra virus
  • Avian Influenza
  • Psittacosis

A dangerous incident that exposed a worker or any other person to a serious risk to a person's health or safety emanating from an immediate or imminent exposure to ...

  • An uncontrolled escape, spillage or leakage of a substance
  • An uncontrolled implosion, explosion or fire
  • An uncontrolled escape of gas or steam
  • An uncontrolled escape of a pressurised substance
  • An electric shock that is not a serious electrical incident or a dangerous electrical event
  • The fall or release from a height of any plant, substance or thing
  • The collapse, overturning, failure or malfunction of, or damage to, any plant that is required to be authorised for use in accordance with the regulations
  • The collapse or partial collapse of a structure
  • The collapse or failure of an excavation or of any shoring supporting an excavation
  • The inrush of water, mud or gas in workings, in an underground excavation or tunnel
  • The interruption of the main system of ventilation in an underground excavation or tunnel

A serious electrical incident involving electrical equipment where ...

  • A person was killed by electricity
  • A person received a shock or injury from electricity, and was treated for the shock or injury by or under the supervision of a doctor
  • A person received a shock or injury from electricity at high voltage, whether or not the person was treated for the shock or injury by or under the supervision of a doctor (high voltage means a voltage above 1000 V AC or 1500 V ripple-free DC)

A dangerous electrical event involving ...

  • The coming into existence of circumstances in which a person was not electrically safe, if the circumstances involve high voltage electrical equipment; and despite the coming into existence of the circumstances, the person does not receive a shock or injury (high voltage means a voltage above 1000 V AC or 1500 V ripple-free DC)
  • The coming into existence of both of the following circumstances (1) if a person had been at a particular place at a particular time, the person would not have been electrically safe and (2) the person would not have been electrically safe because of circumstances involving high voltage electrical equipment (high voltage means a voltage above 1000 V AC or 1500 V ripple-free DC)
  • Electrical equipment and in which significant property damage was caused directly by electricity or originating from electricity
  • The performance of electrical work by a person not authorised under an electrical work licence to perform the work
  • The performance of electrical work by a person if, as a result of the performance of the work, a person or property was not electrically safe
  • The discovery by a licensed electrical worker of electrical equipment that has not been marked as required under the Electrical Safety Act 2002

If the incident does not fall within one of the above categories, you can still make a claim with WorkCover Queensland using the online claim form.

Your contact details

First name:
Surname:

Middle name:
Telephone/mobile:

Email:
 

TITLE

  • Bishop
  • Brother
  • Captain
  • Chaplin
  • Dame
  • Dr
  • Estate of
  • Father
  • For
  • Lady
  • Miss
  • Mr
  • Mrs
  • Ms
  • Mx
  • Professor
  • Reverend
  • Sir
  • Sister

Notifier's relationship to this incident notification:

e.g. Are you the employer?
** Only these options will allow you to make a claim with WorkCover Queensland for an injured person.

  • ** EMPLOYER
  • ** EX-EMPLOYEE
  • ** SELF EMPLOYED
  • ** WORKER
  • HEALTH AND SAFETY REPRESENTATIVE
  • MANAGEMENT REPRESENTATIVE FOR PERSON CONDUCTING A BUSINESS OR UNDERTAKING
  • MANAGEMENT REPRESENTATIVE FOR PERSON WITH MANAGEMENT OR CONTROL OF A WORKPLACE
  • MEMBER OF PUBLIC
  • OTHER
  • PARENT OF WORKER
  • PRINCIPAL CONTRACTOR
  • QUEENSLAND AMBULANCE SERVICE
  • QUEENSLAND FIRE & RESCUE
  • QUEENSLAND POLICE SERVICE
  • SITE CONTACT
  • UNION ORGANISER
  • WHS OFFICER
  • WORKER - WHS REPRESENTATIVE

Should another person be contacted for further information?

Alternative contact details

First name:
Surname:

Middle name:
Telephone/mobile:

Email:
 

TITLE

  • Bishop
  • Brother
  • Captain
  • Chaplin
  • Dame
  • Dr
  • Estate of
  • Father
  • For
  • Lady
  • Miss
  • Mr
  • Mrs
  • Ms
  • Mx
  • Professor
  • Reverend
  • Sir
  • Sister
  • EMPLOYER
  • EX-EMPLOYEE
  • HEALTH AND SAFETY REPRESENTATIVE
  • MANAGEMENT REPRESENTATIVE FOR PERSON CONDUCTING A BUSINESS OR UNDERTAKING
  • MANAGEMENT REPRESENTATIVE FOR PERSON WITH MANAGEMENT OR CONTROL OF A WORKPLACE
  • MEMBER OF PUBLIC
  • OTHER
  • PARENT OF WORKER
  • PRINCIPAL CONTRACTOR
  • QUEENSLAND AMBULANCE SERVICE
  • QUEENSLAND FIRE & RESCUE
  • QUEENSLAND POLICE SERVICE
  • SELF EMPLOYED
  • SITE CONTACT
  • UNION ORGANISER
  • WHS OFFICER
  • WORKER
  • WORKER - WHS REPRESENTATIVE

Incident details

  • Incident date and time
  • Is the address inside QLD?
  • Incident location description: For Example: Aisle 3, plant operation room tower crane, Elizabeth Street site entrance.
  • Description of incident: Please provide as much detail as possible, for instance: The events that led to the incident. The work undertaken when the incident happened. The overall action, exposure or event that best describes the circumstances that resulted in the injury, illness, fatality or the dangerous event. The object, substance or circumstance which was directly involved in inflicting the injury, illness, fatality or the dangerous event. The name and type of any machinery, equipment or substance involved. Was anyone else involved? Was electricity or electrical equipment involved?
  • Did the incident involve licensed work?
  • Is the workplace a registered major hazard facility?
  • Has the site been secured?
  • Describe any actions taken following the incident to prevent reoccurrence
  • Describe any long term action proposed to prevent a reoccurrence
  • How many people were injured?

Incident details

  • Incident date and time
  • An uncontrolled implosion, explosion or fire
  • An uncontrolled escape of gas or steam
  • An uncontrolled escape of a pressurised substance
  • An electric shock that is not a serious electrical incident or a dangerous electrical event
  • The fall or release from a height of any plant, substance or thing
  • The collapse, overturning, failure or malfunction of, or damage to, any plant that is required to be authorised for use in accordance with the regulations
  • The collapse or partial collapse of a structure
  • The collapse or failure of an excavation or of any shoring supporting an excavation
  • The inrush of water, mud or gas in workings, in an underground excavation or tunnel
  • The interruption of the main system of ventilation in an underground excavation or tunnel

Injured people

Title

  • Bishop
  • Brother
  • Captain
  • Chaplin
  • Dame
  • Dr
  • Estate of
  • Father
  • For
  • Lady
  • Miss
  • Mr
  • Mrs
  • Ms
  • Mx
  • Professor
  • Reverend
  • Sir
  • Sister

Relationship to workplace incident

  • Community Services
  • Contractor
  • Director
  • Jockey
  • Member Of Public
  • Other
  • Partner
  • Self Employed
  • Student
  • Trustee
  • Volunteer
  • Worker
  • Worker - 457 Visa
  • Worker - Apprentice-Trainee
  • Worker
  • Worker - Outworker
  • First name
  • Surname
  • Middle name
  • Gender
  • Description of injury/illness : For Example: fracture, laceration, amputation, strain, electric shock, burn, Q fever.
  • Bodily location: What part of the body was injured (eg. right leg, lower back, chest)
  • Date of birth
  • Home telephone
  • Mobile
  • Work telephone
  • Email : If a claim is being lodged for this injured person, please provide an email address so they can receive a copy of their claim form.
  • Occupation

Treatment given ( Yes / No ) : If Yes

  • Treatment description
  • Place taken for treatment

Place of injury

  • Construction site
  • Moving transport
  • Normal Workplace
  • Other
  • Other private workplace
  • Public thoroughfares

Did the injury happen

  • 1. Working at your normal workplace
  • 11. At work - working from home
  • 2. In a road traffic accident while working
  • 3. At work on a break
  • 4. On a journey to or from work
  • 5. Away from work during a recess period
  • 6. Working away from your normal workplace
  • Date employer notified
  • Name of person injury reported to

Residential address:  ( Yes / No ) : If No

  • Shop no.
  • Building
  • Street no.
  • Street
  • Street type

Show street type

ACCESS
ALLEY
ALLEYWAY
AMBLE
ANCHORAGE
ANNEX
APPROACH
ARCADE
ARTERIAL
ARTERY
AVENUE
AVENUE EAST
AVENUE NORTH
AVENUE SOUTH
AVENUE WEST
BANAN
BASIN
BEACH
BEND
BLOCK
BLOVE
BOARDWALK
BOULEVARD
BRACE
BRAE
BREAK
BRIDGE
BROADWAY
BROW
BYPASS
BYWAY
CAUSEWAY
CENTRE
CENTREWAY
CHASE
CIRCLE
CIRCLET
CIRCUIT
CIRCUS
CLOSE
COLONNADE
COMMON
CONCOURSE
COPSE
CORNER
CORSO
COURT
COURTYARD
COVE
CRESCENT
CRESCENT WEST
CREST
CROSS
CROSSING
CROSSROAD
CROSSWAY
CRUISEWAY
CUL-DE-SAC
CUTTING
DALE
DELL
DEVIATION
DIP
DISTRIBUTOR
DRIVE
ORTH">DRIVE NORTH
DRIVEWAY
EDGE
ELBOW
END
ENTRANCE
ESPLANADE
OUTH">ESPLANADE SOUTH

EXPRESSWAY
EXTENSION
FAIRWAY
FIRETRACK
FIRETRAIL
FLAT
FOLLOW
FOOTWAY
FORESHORE
FORMATION
FREEWAY
FRONT
FRONTAGE
GAP
GARDEN
GARDENS
GATE
GATES
GLADE
GLEN
GRANGE
GREEN
GROUND
GROVE
GULLY
HEADLAND
HEIGHTS

HIGHROAD
HIGHWAY
HILL
INTERCHANGE
INTERSECTION
ISLAND
JUNCTION
KEY
LANE
LANE SOUTH
LANEWAY
LEES
LINE
LINK
LITTLE
LOOKOUT
LOOP
LOWER
MALL
MEANDER
MEW
MEWS
MONTAIGNE
MOTORWAY
MOUNT
STREET TYPE
NOOK
OUTLOOK
PARADE
ORTH
PARADE NORTH
PARK
PARK NE
PARKLANDS
PARKWAY
PART
PASS
PASSAGE
PATH
PATHWAY
PIAZZA
PLACE
PLAZA
POCKET
POINT
PORT
PROMENADE
QUAD

QUADRANGLE
QUADRANT
QUAY
QUAYS
RAMBLE
RAMP
RANGE
RESERVE
REST
RETREAT
RIDE
RIDGE

RIDGEWAY
RIGHT OF WAY
RING
RISE
RIVER
RIVERWAY
RIVIERA
ROAD
ROAD EAST
ROAD NORTH
ROAD SOUTH
ROAD WEST
ROADS
ROADSIDE
ROADWAY
RONDE
ROSEBOWL
ROTARY
ROUND
ROUTE
ROW
RUE
RUN
SERVICEWAY
SHUNT
SIDING
SLOPE
SPUR
SQUARE
STAIRS
STATE HIGHWAY
STATION
STEPS
STRAND
STREET
STREET EAST
STREET NORTH
STREET SOUTH
STREET WEST
STRIP

SUBWAY
TARN
TERRACE
THOROUGHFARE
TOLLWAY
TOP
TOR
TOWERS
TRACK
TRAIL
TRIANGLE
TRUNKWAY
TURN
UNDERPASS
VALE
VIADUCT
VIEW
VILLAS
VISTA
WADE
WALK
WALKWAY
WAY
WHARF
WYND
YARD

  • Suburb/locality
  • Postcode
  • Country

Different postal address? If Yes

Is the address inside QLD?  ( Yes / No ) : If No

  • Shop no.
  • Building
  • Street no.
  • Street
  • Street type

Show street type

ACCESS
ALLEY
ALLEYWAY
AMBLE
ANCHORAGE
ANNEX
APPROACH
ARCADE
ARTERIAL
ARTERY
AVENUE
AVENUE EAST
AVENUE NORTH
AVENUE SOUTH
AVENUE WEST
BANAN
BASIN
BEACH
BEND
BLOCK
BLOVE
BOARDWALK
BOULEVARD
BRACE
BRAE
BREAK
BRIDGE
BROADWAY
BROW
BYPASS
BYWAY
CAUSEWAY
CENTRE
CENTREWAY
CHASE
CIRCLE
CIRCLET
CIRCUIT
CIRCUS
CLOSE
COLONNADE
COMMON
CONCOURSE
COPSE
CORNER
CORSO
COURT
COURTYARD
COVE
CRESCENT
CRESCENT WEST
CREST
CROSS
CROSSING
CROSSROAD
CROSSWAY
CRUISEWAY
CUL-DE-SAC
CUTTING
DALE
DELL
DEVIATION
DIP
DISTRIBUTOR
DRIVE
ORTH">DRIVE NORTH
DRIVEWAY
EDGE
ELBOW
END
ENTRANCE
ESPLANADE
OUTH">ESPLANADE SOUTH

EXPRESSWAY
EXTENSION
FAIRWAY
FIRETRACK
FIRETRAIL
FLAT
FOLLOW
FOOTWAY
FORESHORE
FORMATION
FREEWAY
FRONT
FRONTAGE
GAP
GARDEN
GARDENS
GATE
GATES
GLADE
GLEN
GRANGE
GREEN
GROUND
GROVE
GULLY
HEADLAND
HEIGHTS

HIGHROAD
HIGHWAY
HILL
INTERCHANGE
INTERSECTION
ISLAND
JUNCTION
KEY
LANE
LANE SOUTH
LANEWAY
LEES
LINE
LINK
LITTLE
LOOKOUT
LOOP
LOWER
MALL
MEANDER
MEW
MEWS
MONTAIGNE
MOTORWAY
MOUNT
STREET TYPE
NOOK
OUTLOOK
PARADE
ORTH
PARADE NORTH
PARK
PARK NE
PARKLANDS
PARKWAY
PART
PASS
PASSAGE
PATH
PATHWAY
PIAZZA
PLACE
PLAZA
POCKET
POINT
PORT
PROMENADE
QUAD

QUADRANGLE
QUADRANT
QUAY
QUAYS
RAMBLE
RAMP
RANGE
RESERVE
REST
RETREAT
RIDE
RIDGE

RIDGEWAY
RIGHT OF WAY
RING
RISE
RIVER
RIVERWAY
RIVIERA
ROAD
ROAD EAST
ROAD NORTH
ROAD SOUTH
ROAD WEST
ROADS
ROADSIDE
ROADWAY
RONDE
ROSEBOWL
ROTARY
ROUND
ROUTE
ROW
RUE
RUN
SERVICEWAY
SHUNT
SIDING
SLOPE
SPUR
SQUARE
STAIRS
STATE HIGHWAY
STATION
STEPS
STRAND
STREET
STREET EAST
STREET NORTH
STREET SOUTH
STREET WEST
STRIP

SUBWAY
TARN
TERRACE
THOROUGHFARE
TOLLWAY
TOP
TOR
TOWERS
TRACK
TRAIL
TRIANGLE
TRUNKWAY
TURN
UNDERPASS
VALE
VIADUCT
VIEW
VILLAS
VISTA
WADE
WALK
WALKWAY
WAY
WHARF
WYND
YARD

  • Suburb/locality
  • Postcode
  • Country

Employer details

  • WorkCover policy number
  • Legal name
  • Trading name
  • ABN: must be entered as an 11 digit number with no spaces e.g. 12345678912
  • ACN: must be entered as a 9 digit number with no spaces e.g. 123456789
  • Telephone
  • Mobile
  • Fax
  • Email
  • Main business activity : For Example: Furniture manufacture, domestic construction, steel warehousing.
  • Industrial sector
  • ACCOMMODATION AND FOOD SERVICES
  • ADMINISTRATIVE AND SUPPORT SERVICES
  • AGRICULTURE, FORESTRY AND FISHING
  • ARTS AND RECREATION SERVICES
  • CONSTRUCTION
  • EDUCATION AND TRAINING
  • ELECTRICITY, GAS, WATER AND WASTE SERVICES
  • FINANCIAL AND INSURANCE SERVICES
  • HEALTH CARE AND SOCIAL ASSISTANCE
  • INFORMATION MEDIA AND TELECOMMUNICATIONS
  • MINING
  • OTHER SERVICES
  • PROFESSIONAL, SCIENTIFIC AND TECHNICAL SERVICES
  • PUBLIC ADMINISTRATION AND SAFETY
  • RENTAL, HIRING AND REAL ESTATE SERVICES
  • RETAIL TRADE
  • TRANSPORT, POSTAL AND WAREHOUSING
  • WHOLESALE TRADE

Business address

Is the address inside QLD?  ( Yes / No ) : If No

  • Shop no.
  • Building
  • Street no.
  • Street
  • Street type

Show street type

ACCESS
ALLEY
ALLEYWAY
AMBLE
ANCHORAGE
ANNEX
APPROACH
ARCADE
ARTERIAL
ARTERY
AVENUE
AVENUE EAST
AVENUE NORTH
AVENUE SOUTH
AVENUE WEST
BANAN
BASIN
BEACH
BEND
BLOCK
BLOVE
BOARDWALK
BOULEVARD
BRACE
BRAE
BREAK
BRIDGE
BROADWAY
BROW
BYPASS
BYWAY
CAUSEWAY
CENTRE
CENTREWAY
CHASE
CIRCLE
CIRCLET
CIRCUIT
CIRCUS
CLOSE
COLONNADE
COMMON
CONCOURSE
COPSE
CORNER
CORSO
COURT
COURTYARD
COVE
CRESCENT
CRESCENT WEST
CREST
CROSS
CROSSING
CROSSROAD
CROSSWAY
CRUISEWAY
CUL-DE-SAC
CUTTING
DALE
DELL
DEVIATION
DIP
DISTRIBUTOR
DRIVE
ORTH">DRIVE NORTH
DRIVEWAY
EDGE
ELBOW
END
ENTRANCE
ESPLANADE
OUTH">ESPLANADE SOUTH

EXPRESSWAY
EXTENSION
FAIRWAY
FIRETRACK
FIRETRAIL
FLAT
FOLLOW
FOOTWAY
FORESHORE
FORMATION
FREEWAY
FRONT
FRONTAGE
GAP
GARDEN
GARDENS
GATE
GATES
GLADE
GLEN
GRANGE
GREEN
GROUND
GROVE
GULLY
HEADLAND
HEIGHTS

HIGHROAD
HIGHWAY
HILL
INTERCHANGE
INTERSECTION
ISLAND
JUNCTION
KEY
LANE
LANE SOUTH
LANEWAY
LEES
LINE
LINK
LITTLE
LOOKOUT
LOOP
LOWER
MALL
MEANDER
MEW
MEWS
MONTAIGNE
MOTORWAY
MOUNT
STREET TYPE
NOOK
OUTLOOK
PARADE
ORTH
PARADE NORTH
PARK
PARK NE
PARKLANDS
PARKWAY
PART
PASS
PASSAGE
PATH
PATHWAY
PIAZZA
PLACE
PLAZA
POCKET
POINT
PORT
PROMENADE
QUAD

QUADRANGLE
QUADRANT
QUAY
QUAYS
RAMBLE
RAMP
RANGE
RESERVE
REST
RETREAT
RIDE
RIDGE

RIDGEWAY
RIGHT OF WAY
RING
RISE
RIVER
RIVERWAY
RIVIERA
ROAD
ROAD EAST
ROAD NORTH
ROAD SOUTH
ROAD WEST
ROADS
ROADSIDE
ROADWAY
RONDE
ROSEBOWL
ROTARY
ROUND
ROUTE
ROW
RUE
RUN
SERVICEWAY
SHUNT
SIDING
SLOPE
SPUR
SQUARE
STAIRS
STATE HIGHWAY
STATION
STEPS
STRAND
STREET
STREET EAST
STREET NORTH
STREET SOUTH
STREET WEST
STRIP

SUBWAY
TARN
TERRACE
THOROUGHFARE
TOLLWAY
TOP
TOR
TOWERS
TRACK
TRAIL
TRIANGLE
TRUNKWAY
TURN
UNDERPASS
VALE
VIADUCT
VIEW
VILLAS
VISTA
WADE
WALK
WALKWAY
WAY
WHARF
WYND
YARD

  • Suburb/locality
  • Postcode
  • Country