Register of Injuries Illness Template - Free Download | Page 2
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Register of Injuries Illness Template
Location at time of injury:
How was the injury/illness sustained (cause of injury /illness):
Was any plant, equipment, substance or thing involved in the injury/ illness If yes, please provide details:
Witnesses
Were there any witnesses to the injury/illness Yes or No. If yes, please list name and contact
number for each witness:
Name: Contact:
Name: Contact:
Name: Contact:
Name: Contact:
Name: Contact:
Follow up
Has the injury been reported to the worker’s supervisor Yes or No:
Was any treatment provided Yes or No. If yes, please provide details:
Did the injured worker return to work following the injury/illness If yes, please provide details:
Details of person making this entry
First name: Last name:
Position: Department/team:
Signature: Date:
If you are not the injured worker, did you witness the injury/illness Yes or No
TO BE COMPLETED BY MANAGER/SUPERVISOR OF INJURED / ILL WORKER
Catalogue No. WC03743 0512 ISBN: 978-1-74341-073-8 Page 2 of 3
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Register of Injuries Illness Template