InPlace Care

Your name:

The date today: 

Phone #: 

Your email address: 

Details of the incident / accident:

Place of work: 

The date it happened: 

The time it happened: 

What were you doing? 

Where were you? (location) 

Describe how and what happened.

(Please provide full details, this will identify OH&S actions required, use the back of this page if not enough space to write.)

Details of an injury: (if applicable)

Type of injury: (sprain, needlestick, cut etc)  

Location of the injury on your body: 

Specific cause: (Sharp corner, loud noise, wet floor, hot water etc) 

Did anyone witness this incident / injury?   Yes    No     If ‘yes’ Full name:  

Address: 

Contact #: 

Could this injury have been avoided?    

If ‘yes’ how?  

Treatment:

Was first aid given?  Yes    No  

Treatment: 

First aid attendant (print name) 

Contact #: 

Did you return to work?  Yes    No    If ‘No’

Referred to:                                                    (e.g. Local Doctor, Hospital etc)

Outcome: 

I acknowledge that this report is true and correct and I make it with the understanding that any false information                                                                                                                                                                                                         

could result in the injury and or illness being ineligible for future compensation claims should it be applicable to this incident.

Signed:

Dated:

Office use:

Date this report was received: 

Acknowledgement letter written on: 

By: 

Documented in injury register:

Documented by:

Date: