Accident report

• Client / Site

• Conducted on

  Date

• Prepared by

• Location of incident
  Address

• Type of occurrence

  Select Yes No N/A

  • Yes
  • No
  • N/A

Injured party/ person affected

• Name of injured party

• Date of birth

  Date
• Address
  Address

• Contact telephone number

Incident details

• Description of the occurrence

• Details of first aid/ corrective actions

• first aid treatment given by

• Signature of injured party or representative

  Sign

• Were the emergency services called?

  Yes

  No

  N/A

• Details

Investigation and reporting

• Is the incident reportable under RIDDOR? (injured party taken from site to hospital, injury or work related illness resulting in more than 7 days off work, specified dangerous occurance

  Yes

  No

  N/A

• Report number

• What corrective action can you take to prevent reoccurrence?

• Was the occurrence as a result of a building or equipment defect?

• Record name and contact information from any witnesses here

• Does the occurrence require further investigation? (Please contact Jack Noble-Hawkins on 07525254620 immediately and leave as much of the scene un touched as possible, take photographs of the scene)

  Yes

  No

  N/A

• Add drawing

  Drawing

• Add media

  Media

• Signature

  Sign