Record of Accident - Incident

All sections must be completed.

To be completed by the H & S Coordinator and/or injured person and a copy sent to the H & S Manager, c/o FM Division within 48 hours of the event. (Advise H&S Manager immediately in the event of a serious injury or incident.)

All fields marked with (req) are required

Category

Is it an
(req)

Event


(req)

(req)

(req)

(req)

(req)

(req)
Gender
Date of birth
(req)
Are you

Employment Details

Period of employment (if an Ara employee)

Block, Level, Room
(req)

Mechanism of Event

Mechanism of Event

(req)

Nature of Injury or Disease

Nature of Injury or Disease
(req)

Cause of Injury

Cause of Injury
(req)

Injured Part of Body

Injured Part of the Body
(req)
Type of treatment given
(req)

1 low - 10 high

Agency of Injury

Agency of Injury
(req)

Describe the event


(req)

Prevention



Was a tutor present?
Were ACC forms completed?
(req)
Has time been lost from work or study?

Consent

Consent (in case of an ACC claim)

I authorise the Ara H&S Manager or delegate to obtain medical and any other records that are, or may be relevant to this claim.

I authorise disclosure of my health and other information relating to this claim to: my employer, ACC, contracted health or rehabilitation providers, employee representatives.

Privacy and Opt Out Statement

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