Name of Injured Person
Date of Birth
What part of the body was injured? Describe in detail
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?
Was equipment, tools being used?
Explain what equipment, tools were being used?
What caused the event?
Were safety regulations in place and used?
What was wrong?
Recommended preventive action to take in the future to prevent reoccurence
Were there any witnesses?
Enter witness name
Employee went to doctor/ hospital?
Police were called to the scene
Police reference number