Document text
Notice of Workplace Injury
[YOUR FULL NAME]
[YOUR ADDRESS]
[EMAIL] · [PHONE]
Date of birth: [DATE OF BIRTH]
Job title: [JOB TITLE] · Employee number: [NUMBER]
To: [EMPLOYER'S NAME]
Attention: [MANAGER OR HR CONTACT]
[EMPLOYER'S ADDRESS]
[DATE]
Given by: [EMAIL TO … / HANDED TO … ON …]
Dear [NAME],
Notice of injury at work
I am giving you written notice that I was injured at work.
Date and time of injury: [DATE AND TIME]
Place: [WORKPLACE ADDRESS AND EXACT LOCATION]
What I was doing: [TASK]
How it happened: [SHORT DESCRIPTION]
Injury or illness: [BODY PART AND SYMPTOMS]
Witnesses: [NAMES, IF ANY]
First aid or treatment: [FIRST AID / DOCTOR / HOSPITAL, DATE]
Time off work: [NONE / STOPPED WORK ON … ]
I first told [NAME OF PERSON] about the injury verbally on [DATE].
Please:
record the injury in the register of injuries;
notify your workers compensation insurer (claims service provider) within 48 hours of being told, and send me the claim number and the insurer's contact details;
give me a workers compensation claim form;
tell me who at work will be my contact for the claim and return to work.
My treating doctor is [DOCTOR'S NAME AND PRACTICE]. I will provide a certificate of capacity.
This notice does not affect any other rights I have.
Yours sincerely,
____________________
[YOUR FULL NAME]
For me
[ ] Notice given on [DATE] — signed copy or sent email kept
[ ] Certificate of capacity from my doctor: [DATE]
[ ] Claim number from the insurer: [NUMBER]
[ ] Claim form lodged — 6 months from the injury: [DATE]
[ ] If the employer did nothing: notify through icare online