Forms - ACC Samoa

Work Related Accident After Hours Injury Sport Injury Scheme

Employer’s Report of Work Related Accident

First Name *

Last Name *

Date of Birth

Address

Date of Accident

Time of Accident

Place of Accident

Was worker injured in the course of employment?

Yes No

Describe how the accident happened

Where was the worker taken after the accident?

When was the accident reported to you?

Who reported the accident?

What were the worker’s injuries?

Date first attended to by doctor

Name of attending Doctor

Was the worker on your payroll when the accident occurred?

Yes No

Have you paid the ACC levy on this worker’s salary?

Yes No

Date worker was first employed

Occupation of injured worker

Worker’s NPF No

Present pay rate WST

Normal working hours per week

Will worker likely lose any earnings as a result of the accident?

Yes No

Report Form of Worker Injured After Hours

First Name *

Last Name *

Address

Contact Number

Date of Accident

Place of Accident

Time of Accident

Describe how the accident happened?

Hospital where injured worker was taken after the accident?

Who reported the accident?

Details of Injury

Injuries sustained by injured worker

Date first attended to by doctor

Name of the Attending Doctor

Employment Details

Name of Employer

Present Occupation of the injured worker

Present pay rate WST

Have you paid your ACC Levy?

Yes No

Normal working hours per week

Will you likely lose any earnings as a result of the accident?

Yes No

Sport Injury Scheme Form

Details of Injured Person

First Name(s)

Last Name(s)

Date of Birth

Sex

Age

Address / Village

Details of Accident

Date of Accident

Place of Accident

Time of Accident

Describe how the injury/accident happened

Place where the injured person was taken after the injury/accident

Name(s) of person(s) who reported the injury/accident

Details of Injury

Injuries sustained by injured person / state if death occurred

Date first attended by doctor

Name of attending doctor

Sport Details

Is the person registered in your club/team?

Yes No

Has your club/team paid Sport Levy for the person?

Yes No

Was the person injured in the course of the sport activity?

Yes No

Declaration

I declare that the above particulars are true and correct and that I have not withheld any information. I will advise ACC when the injured person returns to sport.

Name of Club/Team

Address / Phone

Sport Levy Number

Signature of Contact Person

Date of Submission

ACC Report Forms

Employer’s Report of Work Related Accident

Report Form of Worker Injured After Hours

Sport Injury Scheme Form