Register of Injuries Illness Template

Register of injuries / illness- Template
Employers are required to keep a register of injuries that is readily accessible in the workplace
(Under Section 63 of the Workplace Injury Management and Workers Compensation Act 1998).
The manager of any mine or quarry, or the occupier of any factory, workshop, office or shop is
responsible for this register of injuries.
Requirements of injury and illness registration

Employers must keep a Register of Injuries at each workplace for workers to record any
workplace injury or illness

The register of injuries may be kept in electronic form only if the employer provides education,
training and facilities to ensure that workers are able to access the register.

An injured worker (or someone acting on their behalf) must notify the employer in writing, or
verbally, of any work-related injury or illness as soon as possible after an injury has happened

Employers need to provide written confirmation to the injured worker that they received
notification of the injury or illness

Employers need to provide a signed and dated copy of this entry to the injured or ill worker.
(INSERT YOUR BUSINESS NAME HERE)
(INSERT NATURE OF BUSINESS / INDUSTRY)
Injured / ill worker’s details
First name:
Last name:
Position:
Department/team:
Volunteers:
Worker’s address:
Date of birth:
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):
Catalogue No. WC03743 0512
ISBN: 978-1-74341-073-8
Page 1 of 3
Location at time of injury:
How was the injury/illness sustained (cause of injury /illness):
Was any plant, equipment, substance or thing involved in the injury/ illness? If yes, please provide details:
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 worker’s supervisor? Yes or No:
Was any treatment provided? Yes or No. If yes, please provide details:
Did the injured worker return to work following the injury/illness? If yes, please provide details:
Details of person making this entry
First name:
Last name:
Position:
Department/team:
Signature:
Date:
If you are not the injured worker, did you witness the injury/illness? Yes or No
Catalogue No. WC03743 0512
ISBN: 978-1-74341-073-8
Page 2 of 3
TO BE COMPLETED BY MANAGER/SUPERVISOR OF INJURED / ILL WORKER
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
(insert company name),
Hereby confirm receipt of this notification.
Signature:
Date:
Information in relation to Work Health and Safety Laws
If you are responsible under the Work Health and Safety (WHS) laws for workers other than employees, for
example contractors, you may not be required under workers compensation laws to record injuries in your
register of injuries. However you may find it helpful to do so. If you wish to include details of all injuries in the
one place you should add space in the template to indicate whether or not the person is an employee for
workers compensation purposes.
Additional resources
Please refer to the Workers Compensation Regulation 2010 (www.legislation.nsw.gov.au) for more detailed
information.
Further Information
To help identify any risks, hazards, systems or procedures that contributed to the injury/illness and to
recommend corrective action to prevent similar incidents, please fill out the “Incident and near miss
investigation form (WC03590 1211)” in the tools and guides section of the WorkCover small business
website.
For further information contact the WorkCover NSW Information Centre on 13 10 50 or visit
workcover.nsw.gov.au.
This information sheet has been prepared using the latest information available to WorkCover NSW. WorkCover NSW
extends no warranties to the suitability of the information for your specific circumstances and disclaims all responsibility
and liability for all expenses, losses, damages and costs you might incur as a result of the information being inaccurate
or incomplete.
Catalogue No. WC03743 0512
ISBN: 978-1-74341-073-8
Page 3 of 3