About the person who had the accident

Name:

Address:

Postcode:

Occupation:

About you, the person filling in this record

Name:

Address:

Postcode:

Occupation:

About the accident

Date and time of accident:

Where it happened (which room or place):

How did it happen? Give the cause if you can.

Were there any injuries?

What were the injuries?

First aid treatment received:

Please sign as the person completing the record.

For the injured party

By signing here I give my consent to my empolyer to disclose my personal information and details of the accident which appear on this form to safety representatives and representatives of employee safety for them to carry out the health and safety functions given to them by law.

For management use only

Complete this section if the accident is reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR). To report, go to www.hse.gov.uk/riddor/report.htm2

Was the accident reportable?

How was the accident reported?

Date reported:
Reported by:

Report reference:

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.