Personal Injury Report
FULL NAME OF INJURED PERSON:
GENDER:
Select
Female
Male
Prefer Not To Say
AFFILIATION:
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Contractor
Employee
Other
Visitor
OTHER:
DATE OF BIRTH:
DATE AND TIME INJURY OCCURRED:
DEPOT LOCATION:
Select
Devonport Depot
Melbourne Depot
Off Site
Sydney Depot
LOCATION INJURY OCCURED:
DESCRIBE INJURY:
DESCRIBE HOW THE INJURY OCCURRED:
WHAT AREA OF THE BODY IS INJURED
Select
Bottom
Chest
Face
Groin
Head
Left Ankle
Left Arm
Left Foot
Left Leg
Left Shoulder
Left Wrist
Lower Back
Neck
Other Or More Than One Area
Right Ankle
Right Arm
Right Foot
Right Leg
Right Shoulder
Right Wrist
Stomach
Upper Back
PLEASE SPECIFY THE AREA/S OF THE BODY INJURED:
WAS PERSONAL PROTECTIVE EQUIPMENT WORN ON THE INJURED AREA OF THE BODY?
Select
No
Yes
WAS PERSONAL PROTECTIVE EQUIPMENT REQUIRED?
Select
No
Yes
WAS PERSONAL PROTECTIVE EQUIPMENT SUPPLIED?
Select
No
Yes
HAVE YOU EVER HAD ANY PROBLEM IN THIS AREA, OR A SIMILAR INJURY BEFORE?
Select
No
Yes
PLEASE PROVIDE DETAILS OF PREVIOUS INJURY OR ISSUE:
WAS THIS INJURY CAUSED BY MANUAL HANDLING ACTIVITIES?
Select
No
Yes
WAS THIS INJURY CAUSED BY THE ACTION OF ANOTHER PERSON?
Select
No
Yes
WHO?
WAS THIS INJURY CAUSED BY ANYTHING THAT WAS UNSAFE?
Select
No
Yes
PLEASE ADVISE WHAT WAS UNSAFE?
WERE YOU AWARE OF AN UNSAFE SITUATION?
Select
No
Yes
WHO WAS THIS UNSAFE SITUATION REPORTED TO?
WHEN WAS THE UNSAFE SITUATION REPORT?
WAS FIRST AID GIVEN?
Select
No
Yes
WAS FIRST AID REFUSED?
Select
No
Yes
WHY WAS FIRST AID REFUSED?
FIRST AID TREATED BY?
TREATED DATE AND TIME:
FIRST AID TREATMENT ADMINISTERED:
REFERRED TO:
Select
Ambulance
Hospital
Medical Practitioner
Other
OTHER, PLEASE PROVIDE DETAILS:
I, the injured person, declare the information in this report is true and correct in every aspect.
SIGN HERE:
Clear Signature
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