Title Page
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Site conducted
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Depot
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Conducted on
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Prepared by
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Location
Particulars of Accident
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Date of accident
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Time
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Location
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Date Reported
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What type of incident has occurred?
The Injured Person (in as much detail as possible)
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Name
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Address
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Date of birth
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Phone number
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Length of employment - with the company
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Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
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Specify injured part of body
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Photo Evidence
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Harm Level
The Accident
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Describe what happened
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What caused the accident?
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Details of Witnesses
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Name
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Position
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Contact number
Treatment of IP
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Was First Aid given?
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Who administered the first Aid treatment?
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Has the injured person gone to Hospital?
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What hospital?
Reporting & Sign Off
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Has the accident been reported to SHEQ?
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What date was it reported?
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Report immediately!
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Signature
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Date
