Opera Australia Incident and Injury Report Form - Confidential
This form is used to report OHS incidents and injuries and near misses. The form is used for staff, contractors, volunteers and visitors.
A separate form is completed for each person with a work related injury. It is a requirement that:
1. All work related incident/injuries are reported to the immediate manager and Human Resources, as soon as possible.
2. All injuries are notified on this form as soon as possible to assist early treatment and support and to meet legal reporting requirements.
If an injured person is unable to complete this form having otherwise notified the injury, the manager or another staff member should complete and submit it.
1. DETAILS OF THE PERSON INJURED OR INVOLVED IN THE INCIDENT
First Name (of Injured Person)
Last Name (of Injured Person)
Date of Birth (of injured person)
Administration and Shared Services
Workshop and Scenic Art
Wigs and Wardrobe
Major Projects (HOSH, Aida, Bowl)
Touring and Outreach
Work Telephone Number
Home Telephone Number
Mobile Phone Number
Category of Staff
Gender of Injured Person
2. INCIDENT DETAILS
Date of Incident
Time of Incident (please insert in 24-hour format)
Production/Event Name (insert N/A if not applicable)
Description of Incident
What and how and incident and/or injury occurred.
Description of Location
Where did it happen? (e.g. on stage, wardrobe area, workshop etc)
Journey to/from work
Vehicle Accident (work)
Details of Any Eyewitnesses to the Incident
Please provide all eyewitnesses' names, job titles, and contact numbers. If no eyewitnesses, please insert N/A.
Describe Any Immediate Action Taken?
Was any action taken to rectify the situation? E.g. did the injured person refrain from using any part of their body, were there any adjustments made the tools or sets?
Did an injury result from the incident?
If Yes, complete sections 3, 4 and 5.
3. INJURY DETAILS
Type of Injury
Body Part Affected
4. FIRST AID / IMMEDIATE TREATMENT DETAILS
Please provide full name, date, time and description of treatment administered.
Further Treatment Required?
Details of Treating Doctor / Hospital
5. WORK STATUS
At work, normal duties
At work, suitable duties
6. DETAILS OF PERSON REPORTING
Name of Person Reporting Injury
Job TItle of Person Reporting Injury
Follow up required?
Please indicate whether a workers compensation claim needs to be lodged for the purposes of taking treatment or time off as a result of this injury.
Unsure, to advise.
No follow up required.
Yes, treatment required/possible loss of time. Need to lodge claim.
Please upload any additional documents such as a WorkCover Certificate of Capacity, doctor's certificate, receipts, or first aid treatment paperwork. Without supporting paperwork and a WorkCover Certificate of Capacity, your claim cannot be lodged.
By ticking this box, I confirm that the information provided above is accurate to my knowledge, and I consent to the use of this information for the purposes of Workers Compensation and Injury Management. I understand that this information may be disclosed to external providers in the management of a resulting Workers Compensation claim.
This form will be submitted to Human Resources for further action as necessary.
For further information and/or support, please contact either Bill Koukoumas (02 9318 8399) or Nitya Ramaswamy (02 9318 8227) in Human Resources.
If you have receipts and/or certificates of capacity at a later stage, please email them to either Bill.Koukoumas@opera.org.au or Nitya.Ramaswamy@opera.org.au.
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