Basis of Employment
Type of Employment
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Mechanism of Injury/Disease
Agency of Injury/Disease

Please complete the following by ticking the box that best describes the incident and provide an estimate of the lost time associated with the incident

Is the incident a Notifiable Incident (NI)?
Notifiable Incidents are those that involve the death of a person, a serious injury or illness of a person, or a dangerous incident and in accordance with the QLD WHS Act 2011 requires the completion and submission of a Queensland Government FORM 3 V1.10.11 immediately to
Is the incident a Medically Treated Injury (MTI)?
Medically Treated Injuries are those that involve work-related injuries/diseases where medical treatment was required that result in the loss of less than a full shift
Is the incident a First Aid Injury (FAI)?
First Aid Injuries / Minor Injuries are those injuries treated either by a first aid officer, self or medical practitioner (not meeting the criteria for a MTI) that are also recorded in company’s official injury register or other recording system.
Is the incident a Near Miss (NM)?
Near misses are those that involve unplanned incidents that occurred at the workplace which, although not resulting in any injury or disease, had the potential to do so.
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Signature of Those Staff Below