Injury Report Form Particulars of IncidentDate *Time *Location *Type of IncidentInjuryIllnessEnvironmentalNotifiable EventOtherReported by *Role in the event *Phone *Email Address *The injured personName *Age *Address *Phone *WitnessesNamePhoneNamePhoneDescribe the IncidentDescribe any illness or injuryAny protective equipment worn (add all that apply)?HelmetHeadband/haloKnee padsElbow padsWrist GuardsCrash shorts or crash pantsType of treatment providedReferred to:Hospital/ A&EDoctorOtherDetails of other referralNotification and investigation WORKSAFE PHONE: (0800) 030-040 (24 hours)Is this a notifiable event?YesNoIf yes, have you contacted Worksafe?YesNoDate notifiedSend MessageSave as DraftPlease do not fill in this field.
