Title Page
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Site
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Conducted on
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Prepared by
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Location
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Personnel
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Name of organisation
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Branch/department
Particulars of Accident
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Date of accident
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Time
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Location
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Date Reported
The Injured Person
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Name
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Address of residents
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Date of birth
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Phone number
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Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
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Specify injured part of body
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Comments
Damaged Property
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Property or material damaged:
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Attach media (if applicable)
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Nature of damage:
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Attach media (if applicable)
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Object/substance causing damage:
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Attach media (if applicable)
The Accident
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Describe what happened
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What caused the accident?
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Statement from injured party
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How serious could it have been?
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How often is this likely to happen again?
Witness statements
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Name
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Please state what happened
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Signature
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What action has or will be taken to stop another accident like this happening?
Action
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Description
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Completed?
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By whom
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When
Treatment and Investigation of Accident
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Type of treatment given
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Name of person giving first aid
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Doctor/Hospital
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Accident investigated by
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Signature of investigator
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Signature of injured person
