Personal Injury Report

• Report No:

• Client / Site

• Conducted on

  Date

• Completed by

• Location
  Address

• Personnel Onsite

General Details:

• Project / Location:

• Client:

• Time/Date of Incident:

  Date

• Time/Date Incident was reported?

  Date

• Has/Was the injury reported to Coughlan management?

  Select Yes No

  • Yes
  • No

• Why not?

• How long has the injured person being doing this type of work before the incident happened?

  0 - 3 mths

  3 - 6 mths

  6 - 12 mths

  1 - 2 yrs

  2+ yrs

• Was the person being supervised at the time the injury occurred?

  Select Yes No

  • Yes
  • No

• Why not?

• Has the injured person been inducted at this site?

  Yes

  No

  N/A

• Reason:

• Has/Was work stopped due to this injury?

  Yes

  No

  N/A

• Reason why?

• Was this incident reported to the client?

  Select Yes No

  • Yes
  • No

• Who?

• Why?

• Is this a notifiable incident? (safeworkSA, emergency services)

  Select Yes No

  • Yes
  • No

• Who to:

  Select SafeWork SA Police Ambulance Fire Brigade Other

  • SafeWork SA
  • Police
  • Ambulance
  • Fire Brigade
  • Other

• Name of Authority:

• Shift:

  Day

  Night

Injured persons details:

• Name:

• Gender:

  Male

  Female

• Contact No:

• Date of Birth:

  Date

• Next of Kin: (if applicable)

• Contact Number:

• Allergies:

• Current Medications:

Job Task:

• What was the injured person doing at the time of the incident:

• What were other workers doing at the time of the injury?

Worker

• Worker

Injury details:

• Nature of Injury:

  Select Abrasion, Allergy, Amputation, Bite(s), Blindness, Bruise, Burn, Chemical Reaction, Concussion, Electric Shock, Existing Condition, Fracture, Hearing Loss, Heart Attack, Hernia, Laceration, Minor Cuts, Puncture, Rash, Scald, Sprain, Strain, Traumatic Shock, Other,

  • Abrasion,
  • Allergy,
  • Amputation,
  • Bite(s),
  • Blindness,
  • Bruise,
  • Burn,
  • Chemical Reaction,
  • Concussion,
  • Electric Shock,
  • Existing Condition,
  • Fracture,
  • Hearing Loss,
  • Heart Attack,
  • Hernia,
  • Laceration,
  • Minor Cuts,
  • Puncture,
  • Rash,
  • Scald,
  • Sprain,
  • Strain,
  • Traumatic Shock,
  • Other,

• Description of Injury:

• Is this a pre-existing injury?

  Yes

  No

  N/A

• Description of pre-existing injury and how this it is linked together:

• Single or Multiple injuries?

  Single

  Multiple

• Location of Injury:

  Select Ankle Back Chest Ear Elbow Eye(s) Face Finger Forearm Groin Hip(s) Knee Lower Leg Mouth Neck Nose Shoulder Stomach Teeth Thigh Thumb Toe Upper Arm Wrist Other

  • Ankle
  • Back
  • Chest
  • Ear
  • Elbow
  • Eye(s)
  • Face
  • Finger
  • Forearm
  • Groin
  • Hip(s)
  • Knee
  • Lower Leg
  • Mouth
  • Neck
  • Nose
  • Shoulder
  • Stomach
  • Teeth
  • Thigh
  • Thumb
  • Toe
  • Upper Arm
  • Wrist
  • Other

• Location of Primary Injury:

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Location of Secondary and/or subsequent injuries:

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Has the injured had any of the listed conditions in the past?

  Ashmatic

  Cardiac

  Diabetic

  Epilepsy

  Other

Treatment and Handover details

• Type of treatment given at the site:

  Nil

  First Aid

  Refused Treatment

• Witness or Injured Person name & Sign for refusal of treatment

  Sign

• Details of treatment given:

• Name & signature of the person administering the first aid:

  Sign

• Patient discharged to:

  Ambo.

  Hospital

  Med. Ctr

  RTW

  Other

• Time & Date injured person was discharged into others care:

  Date

Medical Information Release Authority: I (injured person) do give permission for my medical providers to supply information to WorkCover SA, Employers Mutual, SafeWork SA, other medical providers and my employers relating to my injury or condition as described on this form. I also do give permission for any medical experts to X-Rays, scans, medical reports or any other information relating to my claim/injury (including copies of). A signed photocopy, scan, PDF, electronic version of this medical authority is deemed as valid as an original. This authority shall remain valid until it is superceded or revoked in writing by the person whose name appears in the box below.

• Name & Signature of injured person (sign, only if you agree with the above statement)

  Sign

• Site Supervisors comments: (if applicable)

• Site Supervisors name & signature:

  Sign

• Safety Managers comments (if applicable)

• Safety Managers name & signature:

  Sign

• Clients Representatives comments (if applicable)

• Clients name & signature:

  Sign

• Company's Management comments: (if applicable)

• Managements name & signature:

  Sign