1. About the person who had the accident
Full Adress and Postcode
2. About you, the individual filling in this record (if you did not have the accident write your address and occupation).
Full Address and Postcode
3. Details of the accident
Where it happened? State location
How did the accident happen?
Give the cause if possible
If the person who had the accident suffered an injury, give details
4. Sign and date (Person filling in the record)
5. For the employee only (complete this box if the accident is reprortable under the Reporting of Injuries, Diseases and Dangerous Occurances Regulations 1995 - RIDDOR).
How was it reported?