Incident details

Injured Person Background

Name of Injured Person

Date of Birth

Telephone Number

Address

City

County

Postcode

Gender

Injury Details
Date and time of event

Exact location of event

What part of the body was injured? Describe in detail

Take photo of the body part that was injured. Annotate as required

What was the nature of the injury? Describe in detail

Describe fully how the accident happened?

What was the employee doing prior to the event?

Take photo of the surrounding environment the employee was in prior to the event

Was equipment, tools being used?

Explain what equipment, tools were being used?

What caused the event?

Add supporting evidence of contributing factors

Were safety regulations in place and used?

What was wrong?

Recommended preventive action to take in the future to prevent reoccurence

Witness Statements

Were there any witnesses?

Add witness

Enter witness name

Contact number

Witness statement

Witness signature
Emergency Services

Employee went to doctor/ hospital?

Doctor's Name

Hospital Name

Police were called to the scene

Police reference number

Sign off
Injured person signature
Supervisor signature
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.