1) Particulars of employer, self employed person or principal. (Business name, postal address and telephone number)

2) The person reporting is

An employer

A principal

A self employed person

3) Location of work place (Track, Building etc)
Add location
4) Personal data of injured person


Residential address
Date of birth
5) Occupation or Job title of injured person ( employees and self employed persons only)

6) The injured person is
7) Period of employment of injured person
8) Treatment of injury
9) Time and date of accident / serious harm
Select date
10) Mechanism of accident/ serious harm
Type of mechanism
11) Agency of accident or serious harm
Enter type of agency
12) Bodypart
Enter bodypart
13) Nature of injury or disase
Enter type
14) Where and how did the accident / serious harm happen?

14 a) photos if applicable
Add media
15) If notification is form employer

Has a investigation been carried out?

Was a significant hazard involved

16) Environmental damage

17) Plant damage

Name and position

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.