Dymocks Group WHS
Incident Reporting

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DG
Dymocks Group — WHS Incident Notification
Internal use • Group WHS Management System · v1.4.5
Use this form to report any work-related incident, near miss, or property/environmental damage. All fields marked * are required. For emergencies call 000 first, then complete this form.
1 · Person reporting
Who is filing this report (this may be different to the person injured)
2 · Where
Business division and location
3 · What happened
Type, date, time, and a brief description
4 · Witnesses
Names & mobiles of anyone who saw the incident
5 · Category
What kind of incident is this?
6 · Person Injured
Details of the injured person
7 · Body Part Affected
Tick all that apply
8 · Nature of Injury
Tick all that apply
9 · Treatment & Severity
What treatment was provided, and was time lost from work?
⚠ Notifiable Incident — immediate action required
Hospitalisation as an in-patient is a notifiable incident under the Work Health and Safety Act 2011 (NSW) s.38.
SafeWork NSW must be notified immediately on 13 10 50, and the site preserved.
The Group CEO and Board Chair must also be notified within 24 hours.
On submitting this report, the management team will be alerted automatically.
Near Miss / Damage Detail
Describe what was nearly damaged or was damaged, the impact and likely cost to repair/replace.

By submitting, you confirm the information above is accurate to the best of your knowledge.

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