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Register of Injuries Illness Template
Has an investigation been conducted into the incident If yes, by whom
What controls have been implemented to ensure the incident doesn’t happen again:
Employer confirmation
I, (print name), of
(insert company name),
Hereby confirm receipt of this notification.
Signature: Date:
Information in relation to Work Health and Safety Laws
If you are responsible under the Work Health and Safety (WHS) laws for workers other than employees, for
example contractors, you may not be required under workers compensation laws to record injuries in your
register of injuries. However you may find it helpful to do so. If you wish to include details of all injuries in the
one place you should add space in the template to indicate whether or not the person is an employee for
workers compensation purposes.
Additional resources
Please refer to the Workers Compensation Regulation 2010 (www.legislation.nsw.gov.au) for more detailed
information.
Further Information
To help identify any risks, hazards, systems or procedures that contributed to the injury/illness and to
recommend corrective action to prevent similar incidents, please fill out the “Incident and near miss
investigation form (WC03590 1211)” in the tools and guides section of the WorkCover small business
website.
For further information contact the WorkCover NSW Information Centre on 13 10 50 or visit
workcover.nsw.gov.au.
This information sheet has been prepared using the latest information available to WorkCover NSW. WorkCover NSW
extends no warranties to the suitability of the information for your specific circumstances and disclaims all responsibility
and liability for all expenses, losses, damages and costs you might incur as a result of the information being inaccurate
or incomplete.
Catalogue No. WC03743 0512 ISBN: 978-1-74341-073-8 Page 3 of 3
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