injury Report form

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All fields are mandatory. If it is not applicable please write N/A.

To be completed for ALL incidents and accidents where an injury has or could have resulted.

injured worker details

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NDIS
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Support Services
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Disability Support Services

Incident Details

Time of Injury

Describe how the injury/illness was sustained

This section should be a brief, factual account of the injury incident. Include impact on staff; who was involved; how, where and when the incident occurred; who did what; who (if anyone) was injured and the nature and extent of injuries (if applicable).

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Cause of Injury

witness 

Client Details

1

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2

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3

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4

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Staff/Carer or Others Details

1

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2

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3

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4

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Follow up

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