Australian Capital Territory
Workers Compensation Insurers Form Specifications 2002 (No 1)
Notifiable instrument NI2002—209
made under the
Workers Compensation Regulations 2002, s 98  (approved protocols about certain documents)

This protocol details the data fields that need to be incorporated into Insurers’ Workers Compensation Form, Register of Injury Form, and Early Injury Notification Form.

Simon Corbell
Minister for Industrial Relations
1 July 2002

ACT Government

AUSTRALIAN CAPITAL TERRITORY

INSURERS’
WORKERS COMPENSATION FORM SPECIFICATIONS

Fields to be included on the Insurers Workers Compensation Form

Please refer to the “Insurer’s Download Specification for the Australian Capital Territory” for more information.  Please note the number in the table below equates to the numbers in the “Insurer's Download Specification”.

No.	Data item	Format	Notes	
File Header	
1	Insurer Reference Code	3 characters	Code provided by ACT Workcover	
2	Insurer Name	Up to 40 characters	Provided by ACT Workcover	
Record Details	
2	Policy Number	20 characters	Policy number at the date of the accident	
48	Employer ABN	14 characters	Australian Business Number issued by the Australian Tax Office	
4	Industry at Location of Accident	4 num. Code	ABS ANZSIC code	
5	Employer Location	157 characters	(see Section 1.7, 7 sub fields exist: 40,40,36,30,3,4,4)	
6	Claim Reference Number	20 characters	Insurers code	
7	Previous Claim Number	20 characters	Provided only once when a claim number changes	
8	Date of Lodgement of Claim	YYYYMMDD8 date characters		
9	Worker's Surname	Up to 30 characters		
10	Worker's First name	Up to 30 characters		
11	Worker's Address	Up to 157 characters		
12	Worker's Date of Birth	YYYYMMDD8 date characters		
13	Worker's Gender	M or F 1 character 	Male, Female	
14	Worker's Country of Birth	4 num. Code	ABS SACC 1998 code	
15	Worker's Language at Home	4 num. Code	ABS SACC 1997 code	
16	Worker's Martial Status	M or N or U 1 character	Married/Defacto, Not married, Unknown	
17	Worker's Dependents	2 num.	Total dependents including spouse, dependent children, others	
18	Worker's Occupation	6 num. code	ABS ASCO 2nd Edition coded - currently 4 digit level	
19	Worker's Duty Status	1 num. Code	6 categories (previously 5)	
20	Worker's Training Status	1 num. Code		
21	Worker's Type of Employment	1 num.		
22	Worker's Hours Worked	4 num.	Usual number of hrs worked per week (including overtime)	
23	Worker's Pre-injury Salary	9 num. Whole dollars	Includes overtime	
24	Date of Occurrence/Report	YYYYMMDD8 date characters		
25	Time of Occurrence	HHMM 4 time characters 	Use 24 hr time.  Code 9999 for Occupational illnesses/diseases	
26	Occurrence Narrative	Up to 150 characters	Description of the event including what led up to it	
27	Injury Address	Up to 157 characters	(see Section 1.7, 7 sub fields exist: 40,40,36,30,3,4,4)	
28	Nature of Injury/Disease	3 num. Code	NOHSC NDS 2nd Edition code (TOOCS 2nd Edition)	

29	Bodily Location of Injury/Disease	3 num. Code	NOHSC NDS 2nd Edition code (TOOCS 2nd Edition)	
30	Mechanism of Injury/Disease	2 num. Code	NOHSC NDS 2nd Edition code (TOOCS 2nd Edition)	
31	Breakdown Agency (formerly “Agency”)	3 num. Code	NOHSC NDS 2nd Edition code (TOOCS 2nd Edition)	
32	Severity Indicator	1 num. Code		
33	Date Ceased Work	YYYYMMDD 8 date characters		
47	Agency of Injury or Disease	3 num. Code	NOHSC NDS 2nd Edition code (TOOCS 2nd Edition)	

Fields to be included on the Register of Injury Form

No.	Data item	Format	Notes	
Company or Business Details	
	Company or Business Name			
	Employer ABN	14 characters	Australian Business Number issued by the Australian Tax Office	
Details of the Injured Worker	
	Workers’ Name			
	Address			
	Suburb			
	Postcode			
	Occupation			
	Age			
	Industry in which worker was engaged			
Details of Accident	
	Date of Injury			
	Time of Injury			
	Nature of Injury			
	Cause of Injury			
Details of Treatment	
	Was first aid provided?			
	By who?			

Witnesses Details	
	Name			
	Position held with the business			
	Contact details			
Person Registering Injury Details	
	Name			
	Position held with the business			
	Contact details			
Signature of person Registering Injury Details	
Date	

Fields to be included on the Early Injury Notification Form

No.	Data item	Format	Notes	
Employer Details	
	Employer ABN	14 characters	Australian Business Number issued by the Australian Tax Office	
	Name		As per policy	
	Address			
	Name of Authorised Person			
	Phone Number			
	Fax Number			
Injured Worker Details	
	Surname			
	Given Name(s)			
	Male or Female			
	Address			
	Suburb			
	Post Code			
	Contact Phone Number/s			
	Mobile Number			
	Date of Birth			
	Occupation			

Accident/Injury Details	
	Injury/Disease Suffered			
	Body Part Affected by Injury/Disease			
	Cause of Injury			
	Date of Injury			
	Time of Injury			
	Exact Location Injury Occurred			
Details of Nominated Doctor Treating Injured Worker	
	Name of Medical Practice			
	Address of Medical Practice			
	Name of Doctor			
	Phone Number			
	Fax Number			
Details of Treatment	
	Person Providing First Aid Treatment			
	Referrals for Further Treatment			
Witness Details	
	Name			
	Position held with the Business			
	Phone Number			
	Fax Number			
	Mobile Number			
Privacy Act Statement to be placed here	

NOTE:  Employer must add the details of the injury/disease on the Injury Register as required under Section 10NA of the Workers Compensation Act 1951 (ACT).

Please note that insurers may choose to combine the Register of Injury Form and the Early Injury Notification Form into one form.