Information
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Site
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Completed on
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
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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
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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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Signed
