IntoWork Safety Your detailsWhat is your first name?*What is your second name?*What is your gender?*MaleFemaleNot statedDate of birthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Your employment detailsEmployment type*CasualDay shiftMorning shiftAfternoon shiftNight shiftIndustry*Select your industryAged care industryAgricultural industryAirline operationsAirport operationsAluminium industryAmbulance and patient transportAmusement, events and recreation industryAnimal care and veterinary servicesAquacultureAsphalt industryAustralian Capital TerritoryBanking, finance and insurance industryBroadcasting and recorded entertainment industryBuilding servicesBuilding, metal and civil construction industriesBusiness equipment industryCement and concrete productsCemetery operationsChildren's servicesChristmas IslandCleaning servicesClerical industryClothing industryCoal export terminalsCoal industryCocos (Keeling) IslandsCommercial salesCommonwealth employmentContract call centre industryCorrections and detentionsDiving servicesDredging industryDry cleaning and laundry servicesEducational servicesElectrical contracting industryElectrical power industryFast food industryFederal police operationsFire fighting servicesFood, beverages and tobacco manufacturing industryFuneral directing servicesGardening servicesGrain handling industryGraphic artsHair and beautyHealth and welfare servicesHospitality industryIndigenous organisations and servicesJournalismLicensed and registered clubsLive performance industryLocal government administrationMannequins and modellingManufacturing and associated industriesMarine tourism and charter vesselsMarket and business consultancy servicesMeat industryMining industryMiscellaneousNorfolk IslandNorthern TerritoryNursery industryPassenger vehicle transport (non rail) industryPet food manufacturingPharmaceutical industryPharmacy operationsPlumbing industryPort authoritiesPostal servicesPoultry processingPublishing industryQuarrying industryRacing industryRail industryReal estate industryRestaurantsRetail industryRoad transport industryRubber, plastic and cable making industrySalt industryScientific servicesSeafood processingSecurity servicesSocial, community, home care and disability servicesSporting organisationsState and Territory government administrationStevedoring industryStorage servicesSugar industryTasmaniaTechnical servicesTelecommunications servicesTextile industryTimber and paper products industryTourism industryUranium mining (incl. construction)Vehicle industryWaste management industryWater, sewerage and drainage servicesWine industryWool storage, sampling and testing industryTraining provided to you Induction training Task specific training ReportWhat would you like to report?*A hazardAn incident Hazard detailsWhat is the hazard?* Manual handling Ground conditions Machine interface Traffic management Environmental Housekeeping Slips, trips, falls Access/Egress Guarding Tool use Electrical PPE Vehicles Sharp edges Hazardous material Other Other hazard*Risk ranking*SevereHighMediumLowDescribe the hazardWhat action have you taken?Is further action required?*YesNoWhat action is required? Incident detailsWhen did the incident happen?Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What time did the incident happen? : HH MM AM PM What is the incident?Near missIncident requiring first aidMajor incident requiring hospitalisationFatalityBullying and HarassmentEnvironmental issueVehicle issueImprovement notificationType of accidentFalls from a heightFalls on the same level (including trips and slips)Hitting objects with a part of the bodyExposure to mechanical vibrationBeing hit by moving objectsExposure to sharp sudden soundLong term exposure to soundsExposure to variations in pressure (other than sound)Repetitive movement with low muscle loadingOther muscular stressContact with electricityContact or exposure to heat and coldExposure to radiationSingle contact with chemical or substance (excludes insect and spider bites and stings)Long term contact with chemical or substanceOther contact with chemical or substance (includes insect and spider bites and stings)Contact with, or exposure to, biological factorsExposure to mental stress factorsSlide or cave-inVehicle accidentOther and multiple mechanisms of injuryUnspecified mechanisms of injuryHave you submitted this to your on-site coordinator?*YesNo Injury detailsType of injuryFractures (excluding of vertebral column)Fracture of vertebral column with or without mention of spinal cord lesionDislocationsSprains and strains of joints and adjacent muscles (include acute trauma sprains and strains only)Intracranial injury, including concussionInternal injury of chest abdomen and pelvisTraumatic amputation, including enucleation of eye (loss of eyeball)Open wound not involving traumatic amputationSuperficial injuryContusion with intact skin surface and crushing injury, excluding those with fractureForeign body on external eye, in ear or nose or in respiratory, digestive or reproductive systems (include choking)BurnsInjuries to nerves and spinal cord without evidence of spinal bone injuryPoisoning and toxic effects of substancesEffects of weather, exposure, air pressure and other external causes not elsewhere classified (includes bends, drowning, electrocution)Multiple injuries (only to be used where no principal injury can be identified)Damage to artificial aidsOther and unspecified injuriesType of disease (if applicable)DeafnessEye disorders (non-traumatic)Other diseases of the nervous system and sense organsDisorders of muscle, tendons and other soft tissues (includes synovitis, tenosynovitis, bursitis)Other diseases of the musculoskeletal system and connective tissueDermatitis and other eczemaOther diseases of skin and subcutaneous tissueHerniaOther diseases of the digestive systemInfectious and parasitic diseasesDiseases of the respiratory system (include asthma, legionnaires disease, asbestosis, pneumoconiosis)Diseases of the circulatory system (include heart disease, hypertension, hypotension, varicose veins)Cancers and other neoplasmsMental disordersOther diseasesPart of body injuredEyeEarFaceHead (other than eye, ear and face)NeckBackTrunk (other than back and excluding internal organs)Shoulders and armsHands and fingersHips and legsFeet and toesInternal organs (located in the trunk)Multiple locations (more than one of the above)General and unspecified locations This iframe contains the logic required to handle Ajax powered Gravity Forms.