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Injury Report
1. Your Details
First Name *
Last Name *
DOB *
Occupation *
Phone *
Email *
Address *
Town *
State *
NSW
QLD
VIC
ACT
TAS
NT
SA
WA
Postcode *
2. Incident
Date of Incident *
Time of Incident *
Describe Incident *
Names of any Witnesses
Medical Treatment Needed? *
No
Yes
Date of Treatment
What treatment and any time off work?
Prevention *
suggest what should be done to stop it happening again
