Report a safety issue - Injury

Use this form to report an injury

Details of injured person

First name *

Last name *

Sex *

Male

Female

Home address *

Post code *

State *

Contact number

Description of events

Site address where incident occurred *

Date and time of incident *

What happened? *

Type of injury

(e.g. bruise, cut, fracture, grit in eye) and part of body injured (e.g. left arm, lower back)

Has it been reported to the site supervisor? *

Yes

If so, when was it reported?

Year

Month

Day

Name of site supervisor

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