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Report New Incident or Hazard

Please complete details and click the Submit button.

Attachments can be uploaded on next screen after Submit

Fields marked with a ' * ' are mandatory.

This form is for external submissions, if you are a Student or Staff member of La Trobe University please fill in the report after logging in here.

Incident / Hazard Details

Type: * Incident Hazard Near Miss

Date (dd/mm/yyyy): *
Time (hh:mm am/pm): : Enter time incident occurred, if known
Campus: *
Location * Include exact location and type of premises ( /250 characters)
Zone: *
Incident/Hazard Description Category *

Description* What were you doing at the time? How did the incident occur? Describe the hazard (/250 characters)

Actual Consequence: *

Potential Consequence: * Minimal - Basic First Aid / Minor asset damage
Minor - Medical attention / Moderate asset damage
Moderate - Serious injury / asset destroyed
Major - Fatality / critical assets unusable for weeks
Catastropic - Multiple fatalities / critical assets destroyed

Report Submitter Details

Title (e.g. Mr,Mrs,Dr):
Given Names: *
Family Name: *
Email address:
Relationship to La Trobe:*
Address 1:*
Suburb/Town :*
State :*
Postcode:*
Business Phone:
Mob:
Home:

Injured Person Details

Did the Incident cause an injury to any person? * No Yes

Injured person personal details

Are you the injured person? No Yes Clicking 'Yes' copies the identity data specified above

Relationship to La Trobe:*

Injured Staff Email Address:

Given Names: *
Family Name: *
School / Division / Dept:
Occupation / Title:
Gender Identity: *
Birth Date: --

Injured person contact details

Address 1:
Address 2:
Suburb/Town :
State :
Postcode:
Home Phone:
Mob:
Business Phone:

Injury details

Injury Category:*

Mechanism of injury/illness:*

Agency of injury/illness:*

Nature of injury/illness:*

Injury/illness location:*

Treatment details:*

Name of first aider:

First aider contact:

Hospital details:

Details of Injury:* (/ 250 characters)

Medical Attention Provided:*
Please note: if first aid has been administered a hard-copy of the Record of Treatment must be kept in the department for 7 years.

Has a First Aid Record of Treatment been completed? * No Yes

Property Damage Details

Did the incident cause any property damage? * No Yes

Property type *

Property description * Describe the property stolen/lost/damaged (approx / 250 characters)

Witnesses

No	Given Names	Family Name	Contact Phone No.
1
2
3

Attachments can be uploaded on next screen after Submit

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