Accident report - Search

• Conducted on

  Date

• Prepared by

Details of the affected person

• Full Name of the Affected Person

• Address of the Affected Person

• Telephone Number of the Affected Person

• Is he or she:

  Member of Public

  Employee

  Associate

  Ltd Co Contractor

  Other

• Details of the limited company, including whether the person is self employed (CIS or PSC) or works via an umbrella company?

• Is the affected person likely to be off work or on light duties for more than 7 days?

  Yes

  No

If unknown, this must be monitored and reported to Norman Lamond and AskLegal@search.co.uk if the injured person is off or on light duties for more than 7 days due to their injuries (including weekends).

Incidents details

• Date and Time of Accident/Incident

  Date

• Where did the accident/incident occur and, if at a customer site, what is the name of the customer?

• Who actually controls the area where the accident/incident occurred?

• What happened? Describe the type of work being carried out when the accident/incident occurred, the series of events and the nature of the injuries

• Were there any witnesses to the accident/incident?

  Yes

  No

• Name of the witness

• Address of the witness

• Telephone number of the witness

• Are you providing a signed witness statement?

  Yes

  No

  To follow

• Why not?

First aid

• Was the affected person

  Select Treated on site Returned to work Taken to Hospital Given Resuscitation

  • Treated on site
  • Returned to work
  • Taken to Hospital
  • Given Resuscitation

• Time of First Aid was provided

  Date

• First Aid was provided by

• Describe First Aid given

Action

• What external factors, if any, led to or caused the accident/incident?

• Has action been taken to try and avoid a recurrence of the accident/incident?

  Yes

  No

Sign off

• Person completing report

• Signature

  Sign