Accident Form

• Document No.

• Audit Title:- first aid or accident

• Client / Site

• Staff in attendence

• Name of reporting officer

• Position of reporting officer

• If first aid was administered who was the first aider

• Name of injured party

• Address of injured party
  Address

• Age of injured party

• Contact number

• Date and time of accident / first aid

  Date

• Location of accident / injury

• Description of accident / injury

• Details of injuries / damage sustained

• Addition information I.e weather, lighting, flooring, footwear or any other information that may aid the investigation.

• Was medical / first aid treatment administered on site

  Yes

  No

  N/A

• What first aid equipment was used.

  Yes

  No

  N/A

• Was the first aid bag replenished

  Yes

  No

  N/A

• Did injured party go to hospital

  Yes

  No

  N/A

• If injured party attended hospital give details

Witnesses

• Witness 1 details

• Witness 2 details

• Witness 3 details

Accident investigation

• To whom the accident / injury was first reported

• Date and time accident / injury was first reported

  Date

• Photos taken

  Yes

  No

  N/A

• CCTV footage available

  Yes

  No

  N/A

• Detail any actions taken to prevent recurrence.

• Signature of reporting officer

  Sign