Incident / Accident Notification Incident / Accident Notification (Updated) Type of Incident * Bullying & Harassment Motor Vehicle / Road Incident Discrimination Near Miss / Dangerous Occurrence Environmental Property Damage First Aid Injury Medical Treatment Injury Other Date of incident * e.g. August 12, 2022 Time of incident * State * Select your StateCaliforniaOther Client / Company Name where incident occurred * Company contact If known. Incident address * Describe specific location of incident e.g. aisle 3, plant operation room, tower crane the Elizabeth Street entrance side of the site. Description of incident * Please provide as much detail as possible, for instance: the events that led to the incident; the work being undertaken when the incident happened; the overall action, exposure or event that best describes the circumstances that resulted in the injury, illness, or dangerous incident the name and type of any machinery, equipment or substance involved. Was anyone else involved? If the incident relates to bullying, harrassment or discrimination, what action would you like ColdStaff to make? Did the incident involved licenced work? Yes No If YES, please provide details of the type of licensed work Are you injured as a result of this incident? * Yes No If Yes please contact the office immediately. Personal Details I want to remain anonymous First name Last name Date of birth Contact phone number Email Address Occupation / Position at workplace Main duties. reCAPTCHA If you are human, leave this field blank. Submit form
