Injured Person Background

Name of Injured Person

Date of Birth

Telephone Number






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