Injury Report & Investigation

• Site conducted

  Select

• Document Version - 3

• Document No.

• Injury severity:

  Injury

  Minor Injury

  Moderate Injury

  Severe Injury

• Name of Injured worker:

• Client / Site:

• Form completed on:

  Date

• Person completing this form:

• Host Employer Site Location:
  Address

Report Details

• Date & Time of Injury

  Date

• Date & Time of Report

  Date

• Name of on-duty supervisor at time of injury?

Details of Injured Person

• I authorise Right Connect to take my photograph for use in this report.

• Add media

  Media

• Title:

  Miss

  Ms

  Mrs

  Mr

  Other

• Full Name:

• Gender:

  Male

  Female

  Other

• Please specify

• Address:
  Address

• Contact phone number:

• Email:

• Date the worker commenced employment:

  Date

• What is the workers occupation?

• What are the workers main tasks?

Injury Details

• I authorise Recruitco to take photographs of my injury for use in this report.

• Add media

  Media

• Type of injury or illness? (select all that apply)

  Select Superficial Open Wound Fatality Concussion Sprain Laceration Respiratory Eye Injury Burns Fracture Electrocution Slip Trip or Fall Strain Dislocation Struck by object Entanglement Assault Muscle & Tendon Nerve & spinal cord Amputation Intracranial Other Injury

  • Superficial
  • Open Wound
  • Fatality
  • Concussion
  • Sprain
  • Laceration
  • Respiratory
  • Eye Injury
  • Burns
  • Fracture
  • Electrocution
  • Slip Trip or Fall
  • Strain
  • Dislocation
  • Struck by object
  • Entanglement
  • Assault
  • Muscle & Tendon
  • Nerve & spinal cord
  • Amputation
  • Intracranial
  • Other Injury

• Describe type of injury or illness

• Parts of body affected? (select all that apply)

  Select General Ailment Head Eye (Left) Eye (Right) Ear Nose Throat Neck Back (Upper) Back (Lower) Arm - Upper (Right) Arm - Upper (Left) Arm - Elbow (Right) Arm - Elbow (Left) Arm - Forearm (Right) Arm - Forearm (Left) Wrist (Right) Wrist (Left) Hand (Right) Hand (Left) Chest Abdominal / Stomach Groin / Anus Leg - Upper (Right) Leg - Upper (Left) Leg - Knee (Right) Leg - Knee (Left) Leg - Lower (Right) Leg - Lower (Left) Ankle (Right) Ankle (Left) Foot (Right) Foot (Left) Shoulder (Left) Shoulder (Right) Other

  • General Ailment
  • Head
  • Eye (Left)
  • Eye (Right)
  • Ear
  • Nose
  • Throat
  • Neck
  • Back (Upper)
  • Back (Lower)
  • Arm - Upper (Right)
  • Arm - Upper (Left)
  • Arm - Elbow (Right)
  • Arm - Elbow (Left)
  • Arm - Forearm (Right)
  • Arm - Forearm (Left)
  • Wrist (Right)
  • Wrist (Left)
  • Hand (Right)
  • Hand (Left)
  • Chest
  • Abdominal / Stomach
  • Groin / Anus
  • Leg - Upper (Right)
  • Leg - Upper (Left)
  • Leg - Knee (Right)
  • Leg - Knee (Left)
  • Leg - Lower (Right)
  • Leg - Lower (Left)
  • Ankle (Right)
  • Ankle (Left)
  • Foot (Right)
  • Foot (Left)
  • Shoulder (Left)
  • Shoulder (Right)
  • Other

• Please describe injury location

• Describe this injury or illness.

• Did the Injured Person recieve first aid?

  Yes

  No

• Did the Injured Person recieve medical treatment?

  Yes

  No

• What is the Name of the treating doctor?

• Practice name:

• Practice phone:

• Address:
  Address

• What treatment has the injured person recieved?

• Does the worker wish to make an RTWSA claim?

  Yes

  No

Return To Work SA Claim Information

• What is the claim for?

  Select Loss of wages Medical expences Loss of wages and medical expences

  • Loss of wages
  • Medical expences
  • Loss of wages and medical expences

• What Award is the worker paid under?

  Select Building and Construction General On-site Award [MA000020] Clerks - Private Sector Award [MA000002] Food, Beverage and Tobacco Manufacturing Award [MA000073] General Retail Industry Award [MA000004] Health Professionals and Support Services Award [MA000027] Joinery and Building Trades Award [MA000029] Local Government Industry Award [MA000112] Manufacturing and Associated Industries and Occupations Award [MA000010] Professional Employees Award [MA000065] Road Transport and Distribution Award [MA000038] Road Transport (Long Distance Operations) Award [MA000039] Storage Services and Wholesale Award [MA000084] Waste Management Award [MA000043]

  • Building and Construction General On-site Award [MA000020]
  • Clerks - Private Sector Award [MA000002]
  • Food, Beverage and Tobacco Manufacturing Award [MA000073]
  • General Retail Industry Award [MA000004]
  • Health Professionals and Support Services Award [MA000027]
  • Joinery and Building Trades Award [MA000029]
  • Local Government Industry Award [MA000112]
  • Manufacturing and Associated Industries and Occupations Award [MA000010]
  • Professional Employees Award [MA000065]
  • Road Transport and Distribution Award [MA000038]
  • Road Transport (Long Distance Operations) Award [MA000039]
  • Storage Services and Wholesale Award [MA000084]
  • Waste Management Award [MA000043]

• The worker wishes to be identified as Aboriginal or Torres Straight Islander:

  Aboriginal

  Torres Straight Islander

  N/A

• Country of Birth?

• Does the worker need an interpreter?

  Yes

  No

• What Language?

• What Dialect?

• Is the worker an Australian citizen or permanent resident of Australia?

  Yes

  No

• Type of Visa:

• Expiry Date:

  Date

• What was the circumstance in which the injury occurred?

  Select Working at usual workplace Working, had atraffic accident Having a break Travelling to or from work Attending an approved course of study Working elsewhere Other

  • Working at usual workplace
  • Working, had atraffic accident
  • Having a break
  • Travelling to or from work
  • Attending an approved course of study
  • Working elsewhere
  • Other

• Police Report Number:

• Please Specify:

• Did the worker stop work due to the injury?

  Yes

  No

• Date and time worker stopped?

  Date

• Has the worker resumed work?

  Yes

  No

• Date and time worker resumed?

  Date

• The worker has returned to:

  Pre-injury hours

  Less than pre-injury hours

• The worker has returned to:

  Normal Duties

  Modified duties

• Return to Work SA Employer Number:

• Return to Work SA Location Number:

• Return to Work SA Coordinator Name:

• Title:

• Phone Number:

• Email:

• Is the worker Permanent or Casual?

  Permanent

  Casual

• Days of the week worked:

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday Irregular

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday
  • Irregular

• Does the worker have any other current employment?

  Yes

  No

• When was the employer notified of the injury?

  Date

• Who was notified?

• Position of person notified:

• Work Capacity Certificate Details:

  Cleared for normal duties

  Modified Duties

  Unfit for work

• Certificate covers period from:

  Date

• Next review date:

  Date

• RTWSA Claim Number

Authority to Release Information & Worker Declaration

• I Authorise my medical experts to provide my employer's appointed Return to Work Coordinator or Company Representatives with any information relating and/or relevant to my injury, condition or illness. A copy of this authority to release information (including electronic version) is valid.

• I ackknowlege that it is an offence against the Return to Work Act 2014 to make a statement that is false or misleading. The information i have provided is true and not misleading. I Agree to advise my employer if: - My Circumstances change. - I become aware of any matterthat would make the above information false or misleading. - I undertake any employment (paid or unpaid), including self-employment, during my claim.

• Name and signature of injured worker:

  Sign

• Date:

  Date

Describe What Happened

• Describe what happened. Please be detailed but state only facts.

• What were the weather / environmental conditions at the time of the incident?

  Select Indoors Outdoors Cloudy Rain Snow Windy Heatwave Haze Other Clear

  • Indoors
  • Outdoors
  • Cloudy
  • Rain
  • Snow
  • Windy
  • Heatwave
  • Haze
  • Other
  • Clear

• Describe the weather / environmental conditions at the time of the incident

• What area of the site did the injury occur?

• Are you aware of this area?

  Yes

  No

  N/A

• Do you believe you were working in a safe manner?

  Yes

  No

  N/A

• Do you feel like you were rushing/being rushed to perform this task?

  Yes

  No

  N/A

• Were the correct operating methods being used to perform this task?

  Yes

  No

  N/A

• Have you seen an Injury/Incident/Hazard like this occur in the past?

  Yes

  No

• In your opinion, what could have been done to prevent this injury/Incident/Hazard?

• What immediate actions have been taken to prevent reoccurance?

Witnesses/Others Involved

• Please document all people involved in this incident.

Person

Person

• Full Name

• Contact phone number

• What is this person's relation to the incident? (select all that apply)

  Select Reporter of incident Witness Primary person involved Secondary Involvement On-duty supervisor Other

  • Reporter of incident
  • Witness
  • Primary person involved
  • Secondary Involvement
  • On-duty supervisor
  • Other

• Describe this person's relation to the incident

• Please describe this person's involvement with the incident, including all relevant information

Corrective Actions

• Are corrective/further actions required with regard to this incident?

  Yes

  No

• Have all required corrective actions been added as Actions to this inspection?

  Yes

  No

  N/A

• Please add any corrective actions to the appropriate questions above before completing this incident report

Sign Off

• Further action/follow-up/investigation required?

  Yes

  No

  N/A

• Name of person/people to follow up

• Name & Signature of Reporter

  Sign

• Name & Signature of Injured Worker

  Sign
Additional Information

• Date:

  Date

• Comments: