Elumina - Quicksafe

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*:
Hazard type*:
Near miss type*:
Motor vehicle 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*:

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*:

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

Family name*:

Telephone*:

* indicates required fields

Location incident occurred

Division*	Select one... Australian Capital Territory New South Wales Queensland South Australia Tasmania Victoria Western Australia
Exact location*: Provide the address and/or location where the incident occurred (e.g. in the underground carpark at 29 Ringwood St, Ringwood)

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

Vehicle registration:
Vehicle type*:
Value - if known:	$
Nature of damage or loss:
Estimated value of damage or loss - if known:	$

Other driver who was involved

Only provide the information below if there was another driver involved in incident.

Title:
Given name: Please specify the given name (i.e. not an alias)
Family name:
Telephone:
Licence number:
Vehicle registration:
Was at fault:	Yes No
Was injured:	Yes No

Title:

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

Family name:

Telephone:

Licence number:

Vehicle registration:

Was at fault:

Yes No

Was injured:

Yes No

* indicates required fields

Other driver injury details

Nature of injury:
Injured body part:
Description:

Nature of injury:

Injured body part:

Description:

Injured person details

Reporting person is injured person

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

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:

Upload Files [While in the file upload interface hold control to select multiple files.]

Select files to upload: Max file upload size is 16MB

Select files to upload:
Max file upload size is 16MB

Witness list

Name	Telephone	Email	Address
				+ -

Name

Telephone

Address

MEGT (Australia) Ltd incident report form

Details of the incident

Reporting person details

Location incident occurred

Motor vehicle information

Other driver who was involved

Other driver injury details

Injured person details

Injury details

Upload Files [While in the file upload interface hold control to select multiple files.]

Witness list