Title Page
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Shop
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Workers compensation policy number
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Conducted on
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Prepared by
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Location
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ABN
- Dominos Pyrmont - Dragon Trust ABN 64 395 124 495
- Dominos Sydney CBD - The Sandridge Unit Trust - ABN 65 270 425 793
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Company Name
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Company Address
- Pyrmont 212-214 Harris St Pyrmont 2009
- CBD -Corner Jamison & Lang St Sydney 2000
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Company Postal Address
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Employers Phone Number
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Employers Email
Untitled Page
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Injured person’s first & last name
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Injured person’s commencement date of employment
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Injured person’s occupation
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Injured person’s average weekly wage?
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Injured person’s best contact number
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Injured person’s email
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Injured person’s date of birth (DD/MM/YYYY)
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Injured person’s gender
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Address
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Date of injury (DD/MM/YYYY) & time
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Date Employer was Notified
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Did the injury occur whilst performing normal work activities?
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Does the injured person have multiple injuries?
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Tell us briefly about how the injury occurred
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Which general area of the body has been injured? If the injured person has multiple injuries, please indicate the most significant injury in this section
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Where specifically is the injury?
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What is the type of injury? An injury type could be a cut, a broken bone, anxiety, depression or other
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Is the injured person currently admitted to hospital due to their injury?
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Is medical treatment required?
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Does the injured person feel in control of their pain and/or recovery?
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Has the injured person had time off work because of the injury?
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If so, what date did the injured person stop work? (DD/MM/YYYY)
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Has the injured person returned to work?
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Does the injured person have support at work and in their home life?
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Does the injured person have any additional health conditions?
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Employee Name
