NDIS | Disability Service Providers | Enhanced Lifestyles

QF106 WHS / Incident / Near Miss / Hazard


CONFIDENTIAL

  • Sections 1 through to 6 to be fully completed when reporting an Incident
  • Sections 1 & 2 to complete for a Near Miss or Hazard Report
  • “Care Workers” refers to Lifestyles Attendants or Support Workers
  • Please return completed form to the office – whs@enhancedlifestyles.com.au

SECTION 1: My details

Person involved in incident or reporting a near miss or hazard

Incident number (WHS to complete): ________________

What was the location of the incident / near miss / hazard:

Location Title:

Address:

Postcode:

Section 2: (Tick one)

Date:

Date reported:

Incident time:

Who was the incident/Hazard reported to:

Incident / Near Miss description, including people involved

( Attach photos or supply drawings if required)

Section 3 My incident was caused by….

Other

Section 4 My injury was to....

Other

Section 5 My treatment required was…..

Other

Section 6 My lost time was...

I had Hours off from work

I had Days off from work

Report Incidents to Your Manager Immediately

Signing Section

Leave this empty:

Signature arrow


Signature Certificate
Document name: QF106 WHS / Incident / Near Miss / Hazard
lock iconUnique Document ID: 63a5948e0a5b6e7e8d73f4c56c704711e243595f
Timestamp Audit
April 16, 2021 3:56 pm ACSTQF106 WHS / Incident / Near Miss / Hazard Uploaded by Enhanced Lifestyles - enhanced.website@gmail.com IP 125.168.64.82
April 16, 2021 6:29 pm ACSTWork Health and Safety - whs@enhancedlifestyles.com.au added by Enhanced Lifestyles - enhanced.website@gmail.com as a CC'd Recipient Ip: 150.107.191.47
April 19, 2021 2:43 pm ACSTWork Health and Safety - whs@enhancedlifestyles.com.au added by Enhanced Lifestyles - enhanced.website@gmail.com as a CC'd Recipient Ip: 125.168.64.82
April 19, 2021 2:45 pm ACSTWork Health and Safety - whs@enhancedlifestyles.com.au added by Enhanced Lifestyles - enhanced.website@gmail.com as a CC'd Recipient Ip: 125.168.64.82
April 19, 2021 3:07 pm ACSTWork Health and Safety - whs@enhancedlifestyles.com.au added by Enhanced Lifestyles - enhanced.website@gmail.com as a CC'd Recipient Ip: 125.168.64.82
April 19, 2021 3:23 pm ACSTWork Health and Safety - whs@enhancedlifestyles.com.au added by Enhanced Lifestyles - enhanced.website@gmail.com as a CC'd Recipient Ip: 125.168.64.82
April 19, 2021 3:52 pm ACSTWork Health and Safety - whs@enhancedlifestyles.com.au added by Enhanced Lifestyles - enhanced.website@gmail.com as a CC'd Recipient Ip: 125.168.64.82