Accident Record

• Conducted on

  Date

• Prepared by

About the person who had the accident

• Name

• Address

• Postcode

• Occupation

  Employee

  Retail Visitor

  Contractor

  Other

• Comments

About you filling the report out?

• Same as above, who had the accident?

  yes

  no

• Name

• Address

• Postcode

• Occupation

  Employee

  Retail Visitor

  Contractor

  Other

• Comments

About the accident - If appropriate - include photos

• Date and time of the accident

  Date

• State where the accident happened. (State room or place)

• Say how the accident happened?

• What was the cause?

• If the person who had the accident suffered an injury, say what it was?

• Were emergency services called?

  Yes

  No

  N/A

• What medical treatment was given and by whom?

• Is there any changes that can be made to minimize the risk of this happening again?

  Yes

  No

  N/A

Employee Signature

• You are giving consent for my employer to disclose my personal information and details of the accident which will appear on this form to safety representatives and representative of employee safety for them to carry out the health and safety functions given to them by law. If you don't agree please answer no below

  Sign

• I don't want to disclose my personnel information as per statement above

  no