Title Page

  • Completed on

  • Completed by

  • Document No.

Injury Report

Injured Person Details

  • Full Name

  • Age

  • Occupation

  • Contact Number

  • Designation

  • Name of Employer

Injury Details

  • 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.

  • Provide Photos

First Aid Treatment

  • List the body part(s) injured.

  • List the type of injury(s) sustained?

  • Provide details

  • What First Aid was applied?

  • By Whom?

  • Did the injured person return to work after receiving First Aid treatment?

Medical 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?

  • Witness Details

  • Witness
  • Full Name

  • Employer

  • Occupation

  • Contact Number

  • Designation

Notifiable Incident

  • 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?

  • Is the Notifiable Incident a Dangerous Incident (Near Miss)

  • Photos

SafeWork NSW Details

  • Date and Time reported

  • Reported by

  • 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

    2018-08-28 17_09_55-Certificate of capacity_certificate of fitness for work.png
  • Upload WorkCover Certificate of Capacity

  • What actions did the injured person take?

  • Add signature

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