Australian Government Claim For Workers' Compensation Page 5
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823 Did you stop work as a result of the injury or
28 What were you doing when the injury or illness
illness?
happened? For example: loading stores, mooring
vessel.
No
Yes
When did you stop?
/
/
Date
am/pm
Time
29 What equipment, substance and/or actions directly
contributed to your injury or illness? For example:
24 Were you signed off the ship as a result of the
grinder, mooring rope, acid, fell down stairs.
injury or illness?
No
Yes
Date you were signed off
/
/
Date
30 Were there any witnesses to your injury?
Port where you signed off
No
Yes
Name of witness 1
25 What is the nature of the injury or illness you are
claiming for? For example: fracture, loss of sight,
burn.
Contact telephone
(
)
Name of witness 2
26 What part(s) of your body were injured? For
example: left upper arm, right eye, lower back
muscles.
Contact telephone
(
)
If there were more than two witnesses to your
injury please attach details
27 Where did the injury or illness happen? If on board
a ship please state the specific location. For example:
engine room, accommodation, alleyway.
31 Please describe, in your own words, the events that led to your injury or illness, including unexpected events
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SEA01.1 May 2012
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