Register of injuries / illness- template



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Register of injuries / illness- Template
Employers are required to keep a register of injuries that is readily accessible in the workplace (Under Section 63 of the Workplace Injury Management and Workers Compensation Act 1998). The manager of any mine or quarry, or the occupier of any factory, workshop, office or shop is responsible for this register of injuries.
Requirements of injury and illness registration

  • Employers must keep a Register of Injuries at each workplace for workers to record any workplace injury or illness

  • The register of injuries may be kept in electronic form only if the employer provides education, training and facilities to ensure that workers are able to access the register.

  • An injured worker (or someone acting on their behalf) must notify the employer in writing, or verbally, of any work-related injury or illness as soon as possible after an injury has happened

  • Employers need to provide written confirmation to the injured worker that they received notification of the injury or illness

  • Employers need to provide a signed and dated copy of this entry to the injured or ill worker.

(INSERT YOUR BUSINESS NAME HERE)

(INSERT NATURE OF BUSINESS / INDUSTRY)


Injured / ill worker’s details

First name:




Last name:




Date of birth:




Position:





Department/team:




Volunteers:




Worker’s address:




Manager/supervisor’s name:






Injury or illness details

Date of injury/illness:




Time of injury/illness:




am/pm

Nature of injury/illness:




Bodily location of injury/illness (for illnesses include symptoms):




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

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 2016 (www.legislation.nsw.gov.au) for more detailed information.

Further Information

Contact SafeWork NSW Customer Service on 13 10 50 or visit safework.nsw.gov.au.


This information sheet has been prepared using the latest information available to SafeWork NSW. SafeWork 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 of



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