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Register of injuries

Author: Novade Solutions

Published on: 9/20/2021

Register of injuries

General information

Workplace Location

Injured Persons Name

Home Address

Date of Birth

*Male / Female

Occupation

Employers Name

Employers Address

Details of Injury

Date and Time of injury

Activity in which the person was engaged at the time of injury

Exact location where injury occurred

Nature of injury e.g. fracture, burn, sprain, foreign body in eye

Body location of injury, e.g. ear, eye, face, neck

Details of Treatment

*Treatment provided by First Aid Officer

Remarks

*Follow up treatment required (If yes, an Incident Investigation Report must be completed with 24 hours)

Doctor/ Medical Centre attended

Date attended

*Medical Certificate Received

Treatment i.e. x-ray, prescription

*Further consultation required

*Injury Management required (If yes, notify the Return-to-Work Coordinator)

Name of Witness

Address of Witness

Name of Person Providing First Aid

*Signature

Date

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