Injury / incident Details Abrasion Abuse Bruise Cut Type of Injury Fracture Body Location (Circle one or reference in other) Harassment Sprain Strain Trauma ______________ Initial Treatment Received Date / Time of ___/___/____ - ____:____AM/PM Eg First Aid, medical appointment, Treatment ambulance transfer Is it anticipated that any work time will be lost as a Yes / No consequence of this accident / injury? _______________________________________________________ _______________________________________________________ Note any advice provided to the injured person if relevant. _______________________________________________________ Eg Recommended they seek _______________________________________________________ medical review _______________________________________________________ Involved Person’s Name: Signature: Date: / / ECU Sports Supervisor: Signature: Date: / / OSH Representative: Signature: Date: / / Manager: Signature: Date: / / FSC Director: Signature: Date: / / On completion of this form, please pass to your supervisor for action.
Injury / incident Details Type of Injury (Circle one or reference in other) Abrasion Abuse Bruise Cut Fracture Harassment Sprain Strain Trauma ______________ Body Location Initial Treatment Received Eg First Aid, medical appointment, ambulance transfer Date / Time of Treatment ___/___/____ - ____:____AM/PM Is it anticipated that any work time will be lost as a consequence of this accident / injury? Yes / No Note any advice provided to the injured person if relevant. Eg Recommended they seek medical review _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ Involved Person’s Name: Signature: Date: / / ECU Sports Supervisor: Signature: Date: / / OSH Representative: Signature: Date: / / Manager: Signature: Date: / / FSC Director: Signature: Date: / / On completion of this form, please pass to your supervisor for action.
Incident-report-Hardcopy-of-online-form-issue-2-July-2015.docx