City of Greater Bendigo

Details of the incident

Kind of incident*:
Incident type*:
Incident classification:
Description*:
Date and time of incident*: :
Date reported*:

Is this incident sensitive?

Is sensitive:
Please tick this box to ensure confidentiality
of the incident being reported.

Location incident occurred

Division*:
Exact location*:

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Reporting person details

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Given name*:
(i.e. not an alias)
Family name*:

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Injured person details

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Given name:
Family name:

Injury details

Description of injury:
How did the injury occur*:
Injury a result of*:
Injured body part*:
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Medical treatment:
First aiders:
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Provider:
Treatment
provided:
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Witnesses

Add existing employees/third parties:

Manually add witness record [These records can be added as an employer / third party upon processing of the incident]
Name Telephone Email Address
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Notification

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

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Given name*:

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