Personal Details
Full Name
Address
Phone Number
Email
Employment Details
Position/Job Title
Employer/Hotel Name
Employment Status
Full-time
Part-time
Casual
Other
Incident Details
Date of Incident
Location of Incident
Type of Burn/Injury
Description of Incident
Were there witnesses? If yes, provide names/contacts
Medical Treatment
Describe Medical Treatment Received
Name of Hospital/Medical Institution
Time Off Work (if any)
Compensation Claim Details
Claim Amount (if known)
Other Support Sought
Signature
Date