Victoria University incident report form

This is the Victoria University incident & injury reporting system, please complete the following form.

Details of the incident

Kind of incident*:
Incident type*:
Incident classification:
Description*:
(Please don't enter names in free text fields)
Date and time of incident*: :
Date reported*:

Injured person details

(e is not required for employee number)
Employee number:
Given name*:
Family name*:
Contact number:

* indicates required fields

Injury details

How exactly was injury sustained*:
Injury a result of*:
Injured body part*:
+ -
Medical treatment*:
Do you have anything further to add:

Reporting person details

(e is not required for employee number)
Employee number:
Given name*:
Please specify the given name (i.e. not an alias)
Family name*:

* indicates required fields

Witness list

Name Telephone Email Address
+ 

Location incident occurred

Division*:
Exact location*:
(Of where the incident occurred)

* indicates required fields

Reported to supervisor or manager

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

* indicates required fields

Notification

This will send a notification of this reported incident to the specified email address.

Supervisor email address*:

* indicates required fields