Information
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Conducted on
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Prepared by
About the person who had the accident
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Name
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Address
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Postcode
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Occupation
- Grounds Facilitator
- Tree surgeon
- project manager
- site manager
- general manager
- supervisor
- electrician
- fitter
- labourer
- other please state
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Comments
About you filling the report out?
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Same as above, who had the accident?
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Name
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Address
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Postcode
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Occupation
- Grounds Facilitator
- Tree surgeon
- project manager
- site manager
- general manager
- supervisor
- electrician
- fitter
- labourer
- other please state
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Comments
About the accident
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Date and time of the accident
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State where the accident happened. (State room or place)
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Say how the accident happened?
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What was the cause?
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If the person who had the accident suffered an injury, say what it was?
Employee Signature
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You are giving consent for my employer to disclose my personal information and details of the accident which will appear on this form to safety representatives and representative of employee safety for them to carry out the health and safety functions given to them by law. If you don't agree please answer no below
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I don't want to disclose my personnel information as per statement above
