Form 10 - Incident and injury report



WHS FORM 10: INCIDENT AND INJURY REPORTDetails of incident (eg to a worker or visitor) and treatment Date of incidentTime of incident FORMCHECKBOX am FORMCHECKBOX pmNature of incident FORMCHECKBOX Near miss FORMCHECKBOX First aid FORMCHECKBOX Medical treatment/doctor Name of injured person AddressOccupationDate of birth Telephone EmployerActivity in which the person was engaged at the time of injuryExact site location where injury occurredNature of injury – eg fracture, burn, sprain, foreign body in eyeBody location of injury (indicate location of injury on the diagram)Treatment given on siteName of treating person Referral for further treatment? Yes FORMCHECKBOX No FORMCHECKBOX Name of doctor or hospitalWorkCover medicalcertificate received?Yes FORMCHECKBOX No FORMCHECKBOX Attach copies Injury management required? Yes FORMCHECKBOX No FORMCHECKBOX Notify return to work coordinatorName of return to workCoordinator Witness to incident (each witness may need to provide an account of what happened)Witness nameWitness contactWitness nameWitness contact Details of incident (eg property, plant or environmental damage) 32194502540004316730254000 Date of incident Time of incident FORMCHECKBOX am FORMCHECKBOX pm Location of incident Details of damage to Equipment or property 43167305715003219450571500 Name of person who Telephone Received the reportDescription of incident Immediate response actions (eg barricades, isolation of power) to stabilise the situation Reported to Reported to principal contractor?Yes FORMCHECKBOX No FORMCHECKBOX Provide details (when, reported to and reported by): Reported to authorities(WorkCover phone: 13 10 50)?Yes FORMCHECKBOX No FORMCHECKBOX Provide details (when, reported to and reported by):Reported to principal contractor?Yes FORMCHECKBOX No FORMCHECKBOX Provide details (when, reported to and reported by):Reported to workers compensationinsurer?Yes FORMCHECKBOX No FORMCHECKBOX Provide details (when, reported to and reported by): Completed byNamePositionSignatureDate ................
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