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Accident/Incident/Early Reporting Form
Work Area / Department
First Aider (write name clearly)
Time of Incident hh:mm pm / am
Injured Employee Name : Enter here
Time started Shift hh:mm pm / am
Date of Report
Date of birth dd/mm/yyyy:
TREATMENT (Tick appropriate box) Nil
STATUS (tick appropriate box) Permanent Fixed Term Contractor Other (please state)
Discomfort/Injury Details – Body Part
Discomfort/Injury Type (tick)
8. Description of Accident / Incident: (please describe your interpretation of events)
9. Information for Discomfort for Early Reporting:
- When did you first notice discomfort / pain?
- Is it getting worse, better or staying the same?
- Have you had this discomfort/pain before?
- What are you doing to help relieve the discomfort/pain?
- Is there anything else you feel we should know? (note on reverse)
Root Cause(s) of