Sample Management Review Meeting Agenda Template Page 5
ADVERTISEMENT
1
2
3
4
5
6
7Yes
Yes Name of doctor or hospital:
Referral for further
Medical certificate
treatment?
received?
Attach copies
No
No
Yes Notify return to work
Name of return to
Injury management
coordinator
work coordinator
required?
No
Reported to
Yes Provide details (when and whom):
authorities
No
Witness to event (each witness may be contacted to provide an account of what
happened)
Witness
Witness phone
name
number
Witness
Witness phone
name
number
Incident Form Part C:
Notifiable Incident?
No
Yes
Notification:
If it is a notifiable incident, has NSW WorkCover and or Insurer notified?
No
Yes
Body Notified
NSW WorkCover
Date and time of notification
Insurer
Method of notification
Name of notifier
Notes: (eg notification number)
Mental Health Coordinating Council
Psychological Injury Management Guide 2012
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business