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Editable form
An incident report form should be in a drawer, a folder or a shared drive before anyone is hurt, because the first few minutes decide what you can prove later. This free template gives a host employer one document to work through, from stopping work to closing out the actions.
It is an editable Word file for sites that use agency workers in Victoria and New South Wales, with a stop-and-triage sheet first and a near-miss form at the end.
Why the host needs its own incident record
In Victoria, WorkSafe says a host employer is taken to be the employer of a labour hire worker under the Occupational Health and Safety Act 2004, and its duties include notifying WorkSafe of any notifiable incident and consulting the provider and the worker when it investigates. In New South Wales, SafeWork NSW expects a host employer to have a system to report incidents and injuries, investigate them and identify actions to prevent a repeat.
That is hard to do on a night shift. The agency worker may not know your first aid officer, the provider may not know the site, and a witness may go home before anyone writes anything down. Our post on WorkCover and labour hire workers explains why the insurance side and the safety duty sit in different places.
Each state has its own tests. WorkSafe Victoria lists the injuries and events that must be notified immediately, and SafeWork NSW asks for a call on 13 10 50 for a death, a serious injury or illness, or a dangerous incident. The triage table puts those tests where a supervisor can answer them quickly.
What is inside the form
- Part A, stop and triage: a one-page action sequence and a Victoria and New South Wales notifiable incident table written as yes or no questions.
- Parts B and C, incident and person involved: date, time, location, the agency worker's provider, role, supervisor, induction date and relevant licences.
- Parts D and E, what happened and who saw it: a description, a body-part and treatment table, a damage table and a witness list.
- Part F, notifications log: the provider, the regulator, the insurer through the employer, the health and safety representative and management.
- Part G, investigation record: a timeline, contributing factors by task, plant, environment, people, procedures, supervision, and induction and training, and a hierarchy of controls table.
- Parts H and I, actions and close-out: corrective actions with owner, due date and done column, consultation with the health and safety representative, a review and sign-off.
- Near-miss short form: one page for events where nobody was hurt but someone could have been.
How to use it
- Fill in the control table with your document number, site and owner, and replace each [Bracketed Placeholder] once, then save a clean master.
- Print Part A and keep it at the supervisor's desk and the first aid room, and save the rest as a template for each new incident.
- Start a fresh copy for every incident and complete Parts A to F on the day.
- Run the investigation with the provider and the worker involved, then chase the actions until they are done.
Pair it with a labour hire induction checklist so the worker knows how to report before anything goes wrong.
Related Resources
- Our post on WorkCover and labour hire workers for who carries the insurance cost and the safety duty.
- A free labour hire induction checklist for the first shift and the first week.
- A toolbox talk, JSA and hazard report pack for raising hazards before they become incidents.
- A heat risk pre-start checklist for warehouse and outdoor crews in summer.
- A routine pallet racking inspection your team can run.
- WorkSafe Victoria's notifiable incidents page for the Victorian tests.
- SafeWork NSW incident notification for the New South Wales tests.
Frequently Asked Questions
Who notifies the regulator when an agency worker is hurt?
In Victoria, WorkSafe's labour hire host guidance lists notifying WorkSafe of any notifiable incident or injury as a host duty. In New South Wales, call SafeWork NSW on 13 10 50 if you are unsure. Either way, tell the labour hire provider straight away.
Does this replace the regulator's notification form?
No. WorkSafe Victoria takes the call first, then sends a link to its own online notification form for the written report. This template helps you collect the facts for that form and keep your own record.
What if nobody was hurt?
Use the near-miss short form on the last page. SafeWork NSW says all unsafe work is serious whether an injury occurs or not.
Can I edit it for my site?
Yes. It is a Word file with placeholders. Add your own site names, contacts and rows, and delete lines that do not apply. Check the regulator pages for changes before you rely on the notification questions.
Is this legal advice?
No. It is a general guide only. It covers Victoria and New South Wales, and the regulator's current page has the final say.
Have the Form Ready Before Day One
Download the form and put Part A where supervisors can find it. When you need agency workers for your site, you can request staff from Chandler Personnel.
