Australian hardware insert nature of business

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Australian Hardware (INSERT NATURE OF BUSINESS / INDUSTRY) INJURED / ILL EMPLOYEE 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): PART 2 WHS record keeping system to identify patterns of injury Page 1 of 3
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Location at time of injury: Cause of injury /illness: Was any equipment, substance or thing involved in the injury/ illness? If yes, please provide as much details as possible: 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 employees Australian Hardware supervisor? Yes or No: Was any treatment provided? Yes or No. If yes, please provide as much details as possible: Did the injured worker return to work following the injury/illness? If yes, please provide as much details as possible: PART 2 WHS record keeping system to identify patterns of injury Page 2 of 3
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Details of person making this entry First name: Last name: Position: Department/team: Signature: Date: If you are not the injured employee, did you witness the injury/illness? Yes or No TO BE COMPLETED BY MANAGER/SUPERVISOR OF INJURED / ILL EMPLOYEE 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 Australian Hardware , Hereby confirm receipt of this notification. Signature: Date: PART 2 WHS record keeping system to identify patterns of injury Page 3 of 3
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  • Fall '19
  • Injury, Physical trauma, Australian Hardware

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