Find Jobs
Safety
Find Staff
Total Talent Solutions
RPO
MSP
Forms
Incident / Accident Notification
Feedback
Contact Us
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 State
California
Other
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
Submit form
If you are human, leave this field blank.
