Program Injury Report Form

"*" indicates required fields

Select date DD slash MM slash YYYY
Time of Incident*
:
Type of injury*
Type of treatment*
Name of injured FNSW Employee*
Personnel Type*
Gender*
Name of Guardian/Next of Kin*
Name of person reporting the incident*
DD slash MM slash YYYY
Time it was reported*
:
Name of Witness
Does the cause of the injury need to be referred to WHS committee or VSP manager to reduce the risk from causing injury to another person?*
Max. file size: 15 MB.