Page de titre
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Country
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Site
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Project phase
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Customer (If concerned)
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Completed by
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Date of accident
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Time
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Type of event
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victim's company
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Company name
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Victim's first and last name
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Age
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Length of time in function
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Type of contract :
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Situation linked to a third party :
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Name and first name of the third party
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Nature of injury: (most serious one)
- Abrasion, scrapes
- Bruise
- Burn (thermal)
- Concussion (to the head)
- Crushing Injury
- Cut, puncture
- Sprain, strain
- Broken bone
- Abrasion, scrapes
- Other
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Other
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Specify injured part of body
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First informed person in VSB :
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Description of the event
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Immediate actions implemented
Treatment and Investigation of Accident
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Type of treatment given
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Name of person giving first aid
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Has the victim been transported to hospital ?
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To which hospital ?
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By whom ?
