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Initial notification of injury form

Under Workers Compensation legislation all work related incidents that involve a worker, where workers compensation is or may be payable, must be reported to HEM within 48 hours. Notifications received after 4pm on a business day will be considered to be notified on the following business day.

Under Work Health and Safety (WHS) legislation if the incident involves a death, a ‘serious’ injury or a ‘dangerous occurrence’ you must notify SafeWork NSW immediately on 13 10 50. For definitions of these terms see WHS Act 2011 s 35 – 39 or click here for more information.

(req) = Required information. Form cannot be submitted without this essential information.
(imp) = Important information. Please make every effort to complete these fields.

Employer's particulars
Worker's particulars
Other information
To progress with this injury notification, please answer the following three questions: (if unsure please select Yes)

The information you have provided indicates that this injury is in fact a 'notification only', meaning the worker has not received any treatment, has not been provided with a medical certificate, and has not lost any time from work as a result of the incident.

A record of this notification will be retained however there will be no further contact made with you by anyone from HEM.

If the circumstances of this incident change and the worker either receives treatment, is provided with a medical certificate, and/or loses time from work, you must notify HEM immediately and this notification will be updated to a claim.

A 'notification number' will be forwarded to you via the email address you have provided. You should record this number as your reference and provide this number to a HEM representative if you are required to discuss this incident further.

Should you wish to discuss this incident notification further, please contact HEM on (02) 8251 9069

Medical information
Workers Employment details
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