Title Page

  • Name of injured person

  • Conducted on (Date and Time)

  • Fleet manager full name

  • Incident location

General Information

  • Name of driver

  • Driver's license number

  • Car registration number

Injured Person Background

  • Identification number

  • Take photo of ID

  • Gender

  • Date of Birth

  • Telephone Number

  • Address

Injury Details

  • Date and time of event

  • What part of the body was injured? Describe in detail

  • Take photo of the body part that was injured. Annotate as required

  • Describe fully how the accident happened?

  • Take photo of the surrounding

  • Were safety regulations in place and used?

  • What was wrong?

Witness Statements

  • Were there any witnesses?

  • Add witness

  • Witness
  • Enter witness name

  • Contact number

  • Witness statement

  • Witness signature

Emergency Services

  • Employee went to doctor/ hospital?

  • Doctor's Name

  • Hospital Name

  • Police were called to the scene

  • Police reference number

Sign off

  • Injured person (Full Name and Signature)

  • Fleet manager (Full Name and Signature)

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.