Injured Person Details
Name of Employer
Date and time the injury occurred
What task was being performed at the time of the injury?
How did the injury occur?
What was the location on site where the injury occurred? ( Building / Level / Unit / Room )
Third party Property Damage
Was there any third party property damage?
Provide a detailed description of the damage.
First Aid Treatment
List the body part(s) injured.
- Cheek - Right
- Cheek - Left
- Eye - Right
- Eye - Left
- Ear - Right
- Ear - Left
- Lip - Upper
- Lip - Lower
- Back - Upper
- Back - Lower
- Ribs - Right
- Ribs - Left
- Shoulder - Right
- Shoulder - Left
- Upper Arm - Right
- Upper Arm - Left
- Elbow - Right
- Elbow - Left
- Forearm - Right
- Forearm - Left
- Wrist - Right
- Wrist - Left
- Hand - Right
- Hand - Left
- Finger(s) - Right
- Finger(s) - Left
- Groin - Right
- Groin - Left
- Hip - Right
- Hip - Left
- Upper Leg - Right
- Upper Leg - Left
- Knee - Right
- Knee - Left
- Lower Leg - Right
- Lower Leg - Left
- Ankle - Right
- Ankle - Left
- Foot - Right
- Foot - Left
- Toe(s) - Right
- Toe(s) - Left
List the type of injury(s) sustained?
- Broken Bone
- Respiratory Difficulty
- Foreign Body in Eye
- Contact with Energised Electricity
- Slip / Trip / Fall
- Heat Exhaustion
- Sprain / Strain
- Insect Bite / Sting
- Chest Pain
What First Aid was applied?
Did the injured person return to work after receiving First Aid treatment?
Did the injured person attend a medical facility for further medical attention?
Please provide as much information as possible in the following sections
Medical Facility Details
What is the name of the medical facility attended?
Was the person treated as an outpatient and release immediately after treatment?
Were there any witnesses to the actual event?
Reference - WHS Act Part 3
Is the injury a notifiable incident?
Please contact our Systems Manager or HSEQ Advisor immediately. All Notifiable Incidents must be reported to SafeWork NSW.
Is the Notifiable Incident a Serious Injury?
- Immediate treatment as an in-patient in a hospital
- The amputation of any part of his or her body
- A serious head injury
- A serious eye injury
- A serious burn
- The separation of his or her skin from an underlying tissue (such as degloving or scalping)
- A spinal injury
- The loss of a bodily function
- Serious lacerations
- Medical treatment within 48 hours of exposure to a substance
Is the Notifiable Incident a Dangerous Incident (Near Miss)
- An uncontrolled escape, spillage or leakage of a substance
- An uncontrolled implosion, explosion or fire
- An uncontrolled escape of gas or steam
- An uncontrolled escape of a pressurised substance
- Electric shock
- The fall or release from a height of any plant, substance or thing
- The collapse, overturning, failure or malfunction of, or damage to, any plant that is required to be authorised for use in accordance with the regulations
- The collapse or partial collapse of a structure
- The collapse or failure of an excavation or of any shoring supporting an excavation
- The inrush of water, mud or gas in workings, in an underground excavation or tunnel
- The interruption of the main system of ventilation in an underground excavation or tunnel
SafeWork NSW Details
Date and Time reported
Name of SafeWork NSW representative you spoke to on the phone
SafeWork NSW reference number
Did SafeWork NSW release the site at the time of notification?
What instructions were given by SafeWork NSW?
Certificate of Capacity
A worker who has attended a medical facility or doctor’s rooms for treatment must provide the initial WorkCover Certificate of Capacity as proof they are fit/unfit or have limited capacity for work.
Example Certificate of Capacity
Upload WorkCover Certificate of Capacity
What actions did the injured person take?