Non work related injury form

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INCIDENT DETAILS

Full Name*

Contact Number*

Email*

Email Address*

Division*

Work Location or Site Name*

Injury Details*

Does the Injust affect your capacity to perform your job?*

Yes

maximum 1 allowed

Have you seen a doctor or health professional?*

Yes

Other

maximum 1 allowedIf you have booked in an appointment, please select other and enter the date of the appointment.

Mandatory field(s) marked with *