Report An Incident

You are here:
  1. Home
  2. Report An Incident
Please enable JavaScript in your browser to complete this form.

1. Staff Member Details

Name

2. Incident Information

Shift Type
Type of Incident

3. Detailed Description of the Incident

4. People Involved / Witnesses

Witnesses

5. Injury or Harm Sustained

6. Staff Emotional Experience

7. Immediate Actions Taken

Medical attention required?

8. Staff Support Required

What support do you feel you need following this incident?

9. Prevention & Workplace Safety Review

Do you believe this incident could have been prevented?
Click or drag files to this area to upload. You can upload up to 3 files.

10. Staff Declaration

I confirm that the information provided in this report is accurate to the best of my knowledge.

11. Access To Information - Consent Form

I (full name)

of (home address)

,authorise my employer, Jiniaa Youth Services Pty Ltd / Recovery at Work Coordinator to request and receive medical information (either verbal or written) about my (injury/condition) sustained on

whilst under the employ of Jiniaa Youth Services Pty Ltd.

I understand that this information will be discussed and used for the purpose of planning for/and managing my return to and recovery at work.

I acknowledge receipt of the State Insurance Regulatory Authority (SIRA) publication “Injured at work – A recovery at work guide for workers”. The workplace rehabilitation process has been
explained to me, and I agree to participate in this process. I understand that I may, by providing written advice to Jiniaa youth Services Pty Ltd, or my appointed Recovery at Work Coordinator, change or cancel this authority at any time. I authorise Jiniaa youth Services Pty Ltd/appointed Recovery at Work Co-ordinator to take photos of me for the purposes of RTW Plans and/or discussions with my medical team and representatives.

I acknowledge that failure to provide authority may lead to my employer requesting me to attend an Independent medical assessment to obtain the information required.

In accordance with the Australian Privacy Principles, as detailed in the Privacy Act (1988), Gow-Gates Insurance Brokers (acting as the Recovery at Work Coordinator for Jiniaa youth Services Pty Ltd) will maintain the confidentiality of your information and only release information to known parties involved in your rehabilitation and recovery at work as well as those authorised by you.