Title Page
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Location
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Name
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Occupation
1. About the person who had the accident
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Name
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Full Adress and Postcode
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Occupation
2. About you, the individual filling in this record (if you did not have the accident write your address and occupation).
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Name
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Full Address and Postcode
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Occupation
3. Details of the accident
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When it happened?
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Where it happened? State location
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How did the accident happen?
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Give the cause if possible
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If the person who had the accident suffered an injury, give details
4. Sign and date (Person filling in the record)
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Print name
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Sign
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Date
Person who has had the accident (as confirmation they agree the accident has been recorded accurately).
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Print Name
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Sign
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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).
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How was it reported?
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Print Name
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Sign
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Date
