Injured Person Name:

Injured Person DOB:

Department:

Workers Address:

Manager:

Date/Time of injury:

Nature of injury:

Body location:

Location at time of injury:

How was the injury sustained?:

Was any plant, equipment, substance or other thing involved? Provide details.:

Reporter Name:

Reporter Department:

System Item	Yes	No	Comments
Were there any witnesses?
Has the injury been reported to the worker's supervisor?
Was any treatment provided?
Did the injured worker return to work following the injury?

WHS Form 10