Injured Worker Details
Family Name
First Name
Company
Position
Notes
Injury/Illness Details
Time of injury/illness
Nature of injury/illness
Bodily location of injury/illness
Exaction location at time of injury
Describe how the injury/illness was sustained
Was any equipment involved in the injury/illness?
Yes
No
Notes
If yes, please provide details
Employer Confirmation
Signed by
Sign
Witnesses
Were there any witnesses to the injury/illness?
Yes
No
Notes
If yes, please list witness full names and contact numbers
Follow Up
Did the injured worker return to work following the injury?
Yes
No
Notes
Was the injury reported to the workers supervisor?
Yes
No
Notes
Was any treatment provided?
Yes
No
Notes
Details of person making this entry
Family Name
First Name
Position
Signature
Sign
Date
If you are not the injured worker, did you witness the injury/illness?
Yes
No
To be completed by manager/supervisor of injured worker
Has an investigation been conducted into the incident?
Yes
No
Notes
What, if any, controls were implemented to ensure the incident doesn’t happen again?
Employer confirmation
Employer Signature
Sign
Date
Requirements of injury notification:
Employers must keep a
Register of Injuries
at each workplace for employees to record any workplace injury or illness.
An injured worker (or someone acting on their behalf) must notify the employer in writing of any work-related injury or illness within 30 days of becoming aware of the injury or illness.
Employers must provide written confirmation to the injured worker that they received notification of the injury or illness.
Employers should provide a signed and dated copy of this entry to the injured worker.
To make a WorkSafe claim the injured worker must complete a
Worker’s Injury Claim Form
, available from the Australia Post.