1. About the person who had the accident

Name

Full Adress and Postcode

Occupation

2. About you, the individual filling in this record (if you did not have the accident write your address and occupation).

Name

Full Address and Postcode

Occupation

3. Details of the accident

When it happened?

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)

Print name

Sign
Date
Person who has had the accident (as confirmation they agree the accident has been recorded accurately).

Print Name

Sign
Date

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?

Print Name

Sign
Date
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.