Appendix A - WHS Hazard and Incident Report This form is to be used by all employees when reporting a workplace hazard, incident or near miss. Any serious illness or injury must be reported to the organisational director immediately. Part A - To be completed by the person reporting If you are completing the form on behalf of someone else complete their details below: Personal details Employee name: Ely Amiz Position: Travel Specialist Department: Line manager: Enter Department Enter Line manager Staff: Contractor/labour hire: Yes No Yes No Volunteer: Visitor: Yes No Yes No Home address: 1 Any St, Pleasantville NSW 2124 Email: e..y@TTC.com Phone: Mobile: Enter phone no. 0491 ### ### Report details Type of issue: Hazard Near miss Workplace inspection Incident/injury Security Environment Date of hazard/incident: Time: 8/12/20XX 12:30 PM Hazard/incident category: Electrical/physical (ergonomics, manual handling, slips/trips/falls) Biological (disease, mould, infection) Environmental (air quality, pollution, conditions) Psychological (stress, bullying) Chemical (exposure, hazardous materials) Noise Other category: Please specify Description of hazard, incident or near miss: Some full boxes of A4 printer paper stacked dangerously high next to