Name of organisation
Particulars of Accident
The Injured Person
Length of employment - at plant
- Foreign body
- Chemical reaction
Specify injured part of body
Property or material damaged:
Nature of damage:
Object/substance causing damage:
Describe what happened
What caused the accident?
How serious could it have been?
How often is this likely to happen again?
What action has or will be taken to stop another accident like this happening?
Treatment and Investigation of Accident
Type of treatment given
Name of person giving first aid
Accident investigated by