MEGT (Australia) Ltd incident report form

PLEASE CALL THE MEGT INJURY HOTLINE - 1300 365 022 - TO REPORT ALL INJURIES, INCIDENTS, AND NEAR MISSES BEFORE COMPLETING THIS FORM

Details of the incident

Kind of incident*:
Incident type*:
Incident classification:
Description*:
Describe the incident and the activity that
led to the incident including any witnesses
of first persons on the scene and the
action undertaken.
Date and time of incident*: :
Date reported*:

* indicates required fields

Reporting person details

Given name*:
Please specify the given name (i.e. not an alias)
Family name*:
Telephone*:

* indicates required fields

Location incident occurred

Division*
Exact location*:
Provide the address and/or location where the
incident occurred (e.g. in the underground
carpark at 29 Ringwood St, Ringwood)

* indicates required fields

Injured person details

Given name*:
Please specify the given name (i.e. not an alias)
Family name*:
Telephone*:

Injury details

Description of injury*:
Describe the injury that has occurred
as a result of the incident.
How did the injury occur*:
Injury a result of*:
Injured body part*:
+ -
Medical treatment:
Do you have anything further to add:

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Witness list

Name Telephone Email Address
+