What's in this template?
This Incident and Hazard Report Form template gives Australian healthcare practices a single, comprehensive form to record any workplace injury, illness, near miss, dangerous incident or hazard observation. It supports compliance with sections 35 (notifiable incidents) and 38 (record keeping) of the Work Health and Safety Act 2011 and feeds directly into the Hazard and Risk Register.
The form is structured in five parts plus a notifiable-incident decision block:
- Section 35 decision — built-in checklist to decide if the incident is notifiable
- Part A — Reporter and incident details — reporter, person involved, incident type, when and where, description, injury and first aid
- Part B — Initial WHS Officer assessment — immediate causes, underlying causes, control review, risk re-assessment
- Part C — Notifications and external reporting — WHS regulator, workers comp insurer, police, Ahpra, NDIS Commission
- Part D — Corrective actions and review — hierarchy-of-controls action plan with owner and due date
- Part E — Approval and close-out — sign-off by reporter, WHS Officer and PCBU
Editable placeholder fields
{{practice_name}},{{abn}},{{incident_site}}{{whs_officer}}and{{whs_officer_contact}}{{reporter_name}},{{injured_name}},{{incident_date}},{{incident_time}},{{incident_location}}- Notification reference numbers (regulator, workers comp, Ahpra, NDIS Commission)
- Corrective action register fields and signature blocks
Who needs an Incident Report Form?
Every Australian healthcare practice with workers — and every PCBU — needs an incident reporting system. The form supports two distinct legal obligations:
- Notifiable incident reporting (s35) — the WHS regulator must be told immediately when a death, serious injury or illness, or a dangerous incident occurs
- Internal record keeping (s38) — the PCBU must keep a record of every notifiable incident for at least 5 years
Beyond legal compliance, every workers compensation insurer, accreditor and clinical governance framework requires an internal incident process. The form is suitable for:
- General practices, day procedure clinics and specialist practices
- Allied health practices of any size
- NDIS providers — the form also captures NDIS Quality and Safeguards Commission notification fields
- Pharmacies, pathology and diagnostic imaging providers
- Aged care providers and home care services
WHS Act requirement at a glance
Section 35 — Notifiable incidents. A notifiable incident is the death of a person, a serious injury or illness, or a dangerous incident. The PCBU must notify the WHS regulator immediately by the fastest possible means (telephone) and follow up in writing within 48 hours.
Section 38 — Duty to notify and keep records. The PCBU must ensure that written notice of the incident is given as soon as practicable. The PCBU must keep a record of each notifiable incident for at least 5 years from the day notice of the incident is given.
Section 39 — Site preservation. The site of a notifiable incident must not be disturbed until an inspector arrives or the regulator gives directions, except to help an injured person, make the site safe or preserve evidence.
The form's first page walks the reporter through the s35 decision so that high-stakes incidents trigger the regulator notification path automatically.
What counts as a "serious injury" in healthcare?
Section 36 of the WHS Act lists serious injuries and illnesses, with several common in healthcare workplaces:
- Amputation, head injury requiring hospitalisation, serious eye injury, serious burn, spinal injury
- Loss of consciousness from work
- Electric shock
- An infection at work — including occupational Q fever, hep B, hep C, HIV (relevant after needlestick exposure), Mycobacterium tuberculosis, and any infection where the work directly contributed
- Any injury requiring immediate hospitalisation as an inpatient
The form's "is this notifiable?" checklist references these categories so workers can make a quick decision and escalate to the WHS Officer where unsure.
State variations
| State / Territory | Regulator | Notification number | |---|---|---| | NSW | SafeWork NSW | 13 10 50 | | QLD | WorkSafe Queensland | 1300 362 128 | | VIC | WorkSafe Victoria | 13 23 60 | | SA | SafeWork SA | 1300 365 255 | | TAS | WorkSafe Tasmania | 1300 366 322 | | ACT | WorkSafe ACT | 13 22 81 | | NT | NT WorkSafe | 1800 019 115 | | WA | WorkSafe WA | 1300 307 877 |
The form's notification register prompts the WHS Officer to record the date, time, person who notified, and the reference number issued by the regulator.
How to customise this template
- Download the Word document and replace every
{{placeholder}}with your details - Print copies for first aid stations, reception and the staff room — workers should be able to grab the form within seconds
- Brief workers on completing Part A immediately after any incident, near miss or hazard observation
- Train the WHS Officer to complete Parts B–D and decide whether s35 notification is required
- Wire the form into the Hazard and Risk Register — every closed-out incident updates the register
- Retain the form for at least 5 years (longer for serious injuries — see your records management policy)
- Run an annual tabletop drill so the response team has used the form before a real notifiable incident occurs
Related templates and tools
This form is the operational front-end of the WHS document set:
- Hazard and Risk Register — every "Fail" or hazard observation feeds into the register
- Workplace Inspection Checklist — proactive companion that catches issues before they cause incidents
- Return to Work and Injury Management Procedure — used when an incident causes a workers compensation claim
- Manual Handling Policy — referenced in incidents involving lifting or transfer injuries
- Psychosocial Hazards and Workplace Wellbeing Policy — referenced in stress, fatigue, bullying and exposure incidents
- Emergency Evacuation Plan — referenced in fire, gas, flood and structural incidents
For the high-level policy, see the Work Health and Safety Policy in the RACGP library.
Frequently asked questions
What is a notifiable incident?
Section 35 of the WHS Act defines a notifiable incident as the death of a person, a serious injury or illness (defined in s36), or a dangerous incident (defined in s37). They must be reported to the WHS regulator immediately by phone and in writing within 48 hours, and the site must not be disturbed until an inspector arrives or the regulator authorises (s39).
How long do incident records need to be kept?
Section 38(2) requires a PCBU to keep a record of each notifiable incident for at least 5 years from the day notice was given. Many practices keep records for 7 years to align with workers compensation, Privacy Act and accreditation retention rules.
Does this form replace a workers compensation claim?
No. The incident form is the internal WHS record. If a worker is injured and may have a workers compensation claim, the form's Part C prompts the WHS Officer to also notify the workers comp insurer and start the claim process. The Return to Work and Injury Management Procedure documents that process in detail.
Should patients fill out this form if they're injured at the practice?
No. This is a workplace incident form — it captures injury to workers, contractors and others arising from the practice's work. A patient injured by a clinical error should be handled through the practice's clinical incident process and open disclosure framework. A patient injured by a slip-and-fall in the waiting area is captured here as the patient is a "visitor" and the slip is a workplace hazard.
What if the worker doesn't want their name recorded?
The form supports anonymous hazard observations (Part A4 only — without A1/A2 personal details). For injuries, the worker's identity is typically required for first aid records, workers compensation and notification. The Privacy Act requires the practice to handle this information confidentially.
Does the form cover NDIS reportable incidents?
Yes — Part C includes a row for NDIS Quality and Safeguards Commission notification, but the form does not replace the dedicated NDIS reporting form (the Notification of reportable incidents form on the NDIS Commission portal). Use this form for the WHS internal record, then complete the NDIS portal form for reportable incidents involving participants.
Will accreditors accept this template?
Yes, when populated and used. RACGP 5th Edition Criterion QI3.1 (managing clinical risks) and C3.5 (work health and safety) both require a documented incident process. NDIS Practice Standards Core Module 1 (governance) and ISO 45001 also require it. The form's structure — incident details, causes, controls, corrective actions, sign-off — maps to all three frameworks.