Template

Workers' Compensation CCIP Claim Report Form

by Kat La Chapelle, from the Community

20+

This Workers' Compensation CCIP Claim Report Form helps construction teams capture key details after a workplace incident and meet 24-hour reporting requirements. The template includes sections for employee and employer information, incident date and time, body part and injury type, type of work performed, cause of injury, medical treatment details, and witness statements. It also provides fields for supervisor and project manager sign-offs to support accurate documentation, faster claims processing, and safety compliance on construction projects.

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Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

About author

Community

This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.

Template
Workers Compensation Claim Form
This workers compensation claim form helps organisations capture the key details needed after a workplace injury. It records employer information (including ABN and policy details), injured worker details, incident date and time, injury type and location, medical treatment, hospital admission, time off work, and return to work status. The template references Domino’s Sydney CBD and Pyrmont sites but can be adapted for other workplaces. Use as a starting point only and seek professional advice for your jurisdiction and policies.
by Michael Carpenter, from the Community
Downloads: 0
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Template
Work Injury Report Template
Use this Work Injury Report template to document workplace incidents thoroughly and consistently. Record employer and employee details, date and time, location, type of injury, body part affected, activities at the time, equipment involved, and a narrative of how the event occurred. Log treatment provided, healthcare providers, hospitalization, witness details, and return to work dates. Support internal reporting, workers compensation, and safety compliance across industries.
by Dan Elwell, from the Community
Downloads: 0
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Template
First Report of Injury (Form 45) Template
This First Report of Injury (Form 45) template helps retail teams document workplace incidents and workers compensation details. Capture employer and carrier information, employee demographics and wages, accident time and location, descriptions of how the injury occurred, affected body parts, treatment provided, and hospitalization status. Include physician details and signatures to complete a compliant incident report for store locations.
by Eric Zabinski, from the Community
Downloads: 10+
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Template
First Report of Injury Template
This First Report of Injury template helps employers document workplace incidents for workers compensation and safety compliance. Capture employer and carrier information, employee demographics, wages, job and hire date, accident date and location, activity at time of injury, description of how the incident occurred, affected body parts, and harmful objects. Record medical provider details, treatment location, emergency room and hospitalization status, and dates last worked or death if applicable. Includes fields for report preparer and signature to complete the incident record.
by Kelly Phillips, from the Community
Downloads: 10+
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Workers' Compensation CCIP Claim Report Form

About author

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Workers Compensation Claim Form

Work Injury Report Template

First Report of Injury (Form 45) Template

First Report of Injury Template

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Workers Compensation Claim Form

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First Report of Injury (Form 45) Template

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