an injury that nearly occurred and could be prevented in the future) Other: Treatment given on site Mental Health Coordinating Council Name of treating person Psychological Injury Management Guide Yes Name of doctor or hospital: Referral for further treatment No Medical certificate received Yes Attach copies No Injury management required Yes Notify return to work coordinator Name of return to work coordinator No Yes Provide details (when and whom): Reported to authorities No Witness to event (each witness may be contacted to provide an account of what happened) Witness name Witness phone number Witness name Witness phone number Incident Form Part C: Notification: Notifiable Incident No If it is a notifiable incident, has NSW WorkCover and or Insurer notified Yes Body Notified Insurer NSW WorkCover Method of notification Yes No Date and time of notification Name of notifier Notes: (eg notification number) Mental Health Coordinating Council www.mhcc.org.au Psychological Injury Management Guide 2012 Incident Form Part D: Investigation and Follow-Up What actions (if any) contributed to this incident What were the reasons for these actions What conditions (if any) contributed to this incident What were the reasons for these conditions existing Provide details of any further action required eg changes to training, equipment modifications, changes to procedures Mental Health Coordinating Council www.mhcc.org.au Psychological Injury Management Guide Incident Form Part E: Action Plan Preventative actions include what needs to be done, who will do it and when it will be done Person to action: Actions complete: Due Date: No Yes Due date extended to: Additional comments: Completed by Name Position Signature Date Manager’s Signature Date All material presented or produced by the Mental Health Coordinating Council (MHCC) is for guidance purposes only..
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