Injury Notification Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Injured Worker Details

• Name (Last Name, First Name & Middle Name)

• Date of Birth

  Date
• Home Address
  Address

• Male

• Female

• Home Phone Number

• Mobile Number

• Work Phone Number

• Email Address

• Occupation

• Full Time

• Part Time

Injury Details

• Date and Time of the injury

  Date
• Accident Location
  Address

• Injury Type

• Body Part Injured

• What was the worker doing at the time of the injury?

• Was medical treatment given?

  Yes

  No

  N/A

• Medical Treatment Details

• Was there time loss due to the injury?

  Yes

  No

  N/A

• Date and Time when Worker ceased work

  Date

• Was the injury reported to your employer or employer's representative

  Yes

  No

  N/A

• Reported To

• Position

• Phone Number

• Person who notified the injury

• Notifier Phone Number

Accident Investigation Report

• Investigation Date

  Date

• Name of person conducting the investigation

• Workplace Manager

• Health & Safety Representative

• Other

• Name of Person Injured

• Date and Time of Injury

  Date

• How long have you been doing this task?

• Is this part of your normal duties?

  Yes

  No

  N/A

• Has a similar incident occurred previously?

  Yes

  No

  N/A

• Has a risk assessment for the task been completed?

  Yes

  No

  N/A

• Provide the key contributing factors that led to the incident / injury occurring and the immediate cause

• Date employer notified of the injury

  Date

• Documents collected (please attach relevant documents)

• Signature of Person who conducted the investigation

  Sign