Date of notification Name of facility Unit / Department / Ward Date seen/treated/admitted Medical certificate (MC) given Duration of MC WEHU A2 1. Nature of injury © Abrasions (© Amputation T asphyxia © Burns (heat) () Burs (chemical) (3 Bruises and contusions (i Concussions D cuts [Z. Dislocation 2 Effect of electric currents 2. Part of Body Injured D Face (D other specify: Head and Neck Upper Limbs G scalp (2 Upper arms CO skull OC Elbow Dl Eyes RIL C Forearm Clears RIL DB wiist TZ Nose i Hand C2 Mouth Ci Paim 1 Teeth Fingers 1 Neck 3. Mechanism of accident ( Struck against object ( Struck by sliding, falling, flying or other moving object (5 Motor vehicle accident Caught in / or between object (© Fallor slip on same level © Fall from height Injured while handling, lifting or carrying © Contact with extreme temperature (2 Effect of radiation © Fracture © Drown © Laceration Sharp injuries G Sprain & strain [internal injuries [2 splash of blood/body fluid [B Splash of chemicals (11 others (please specify) Torso RIL Back RL D Chest RIL G Abdomen RIL G@ Pewis RIL © Groin RIL RIL Lower Limbs hip (Thigh Oleg Di knee Ankle I Feet DB Toes (Gi Exposure to / or contact with harmful substances / radiation RIL RIL RIL RL RIL RIL RIL Gi Exposure to / or contact with electric currents [GZ Exposure to explosion (© Drowning © crush by moving / sliding object [ Needle stick / Needle prick [2 Physical assault