Form Wor0028a - Workers' Compensation Employer'S Report Form Page 3
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2
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4Agency - refers to the working environment. (machine, means of transport, substance, etc., causing the accident, e.g.
conveyor failed.)
11. Please indicate whether
a) the injury caused by any defect in system of work, machinery or plant.
No
Yes
Please provide details
b) there was any breach of any statutory or other regulations at the time of injury.
No
Yes
Please provide details
c) any serious and wilful misconduct on the part of the worker which contributed to the injury.
No
Yes
Please provide details
d) the injury was caused by the negligence of any person.
No
Yes
Please provide details
12. Reporting of accident
Name of person to whom the accident was reported
Date reported
Time
/
/
am/pm
Name of witness, if any
Address of witness
Postcode
If more than one witness, please attach a list on a separate page.
Do you agree with the details of the occurrence as provided on the Worker’s Claim for Compensation Form?
No
Yes
Please provide details
13. Employment details
Date first employed
/
/
Indicate with a tick (
✓
) the days usually worked each week.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
hrs
mins
hrs
mins
State standard number of hours worked: Per day
Per week
Is this worker subject
What type of visa?
No
Yes
e.g. S457
to a VISA?
1. Was the worker directly employed? (i.e. not a contractor or employee of a contractor)
Yes
No
Please provide details
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