Anonymous Incident Report Portal

Employees shall use this form to anonymously report all work-related injuries, illnesses, or “near miss” events (which could have caused an injury or illness) – no matter how minor. This helps us to identify and correct hazards before they cause serious injuries. This form shall be completed by employees as soon as possible and submitted on the portal for further action.

Form Designer

Anonymous Incident Report

Date of Incident *

Time of Incident (HH:MM)

Name of Employer *

Employer Address *

Department *

Location where incident occurred *

Task being performed at time of incident *

Description of incident *

Witness 1 (Optional)

Witness 2 (Optional)

Nature of injury (e.g. cut, burn, strain) *

Body location of the injury (e.g. shoulder, back) *

First Aid Treatment *

Is the incident required to be reported to WorkSafe Victoria? *

Yes

Had training been provided for the job/task being undertaken? *

Yes

N/A

Was supervision provided? *

Yes

N/A

Was a Risk Assessment e.g. (SWMS) completed? *

Yes

N/A

Are documented work procedures available for this task? *

Yes

N/A

Were any changes made to the standard procedure for the task? *

Yes

N/A

Was PPE & C provided? *

Yes

N/A

Was the correct equipment used to complete the task? *

Yes

N/A

Was the equipment in the correct location? *

Yes

N/A

Was the equipment properly guarded? *

Yes

N/A

Had required preventative maintenance been completed? *

Yes

N/A

Was the equipment working properly? *

Yes

N/A

Had the equipment been modified? *

Yes

N/A

Did any other factors contribute to the incident? *

Can the risk be eliminated? *

Yes

What steps can be taken to eliminate the risk? *

Submit

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