WHS Sensus Site Accident Report

• Accident Report.

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Persons job designation.

• Location
  Address

General Information

• Name of injured Person.

• Address of injured person

• House number and street

• City

• State

  Select QLD NSW VIC SA WA TASMANIA NT

  • QLD
  • NSW
  • VIC
  • SA
  • WA
  • TASMANIA
  • NT

• Postcode

• Home Phone:

• Mobile:

• Sex:

  Male

  Female

• Job Title

• Status:

  Employed

  Subcontract

  Home owner

  General Public

• Date and time of Injury

  Date

• Type of Injury

• Part/s Injured

• Work Time Lost

• Was Professional Medical Treatment Sought.

  Yes

  No

  N/A

• Medical Centre or Hospital attended.

• Address of Medical Centre

• Name of Attending Doctor

• Treatment carried out:

Cause of Injury

• Describe What Happened to Cause the Injury.

• Was there a Witness/es to the Injury?

  Yes

  No

  N/A

• Name of Witness.

• Enter Address of Witness

• Enter contact number:

• Have corrective measures been undertaken?

  Yes

  No

  N/A

• What measures have been undertaken?

Signatures

• Signature of Person Completing Form

  Sign

• Signature of Person Injured

  Sign