Title Page
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Conducted on
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Prepared by
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Location
Accident report
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Every attempt should be made to record and act upon near miss information and ill health (such as upper limb disorders) and not just the “accidents” themselves. Workplace statistics derived from this source provide essential information for safety committees so they can monitor and ensure that preventive action is taken.
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Location of the accident
- WELD SHOP
- PRESS SHOP
- TOP PRESS SHOP
- EARTH MOVER
- PAINT PLANT
- MAINTENACE
- TOOL ROOM / FAB SHOP/ TEST CENTRE
- OLD SPIECAL WHEELS
- DESPATCH
- YARD
- POWDER COAT
- STORES
- OFFICE
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Please enter the date and time that this report was started.
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Take a photo of the injury or injured area
About the person who had the accident
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The Social Security (Claims and Payments) Regulations 1979 Notice of Accidents
Regulation 24 Require the injured worker or person acting for them to give the employer specific details of accidents as soon as practicable either in writing or orally.
These are as follows:
1 Full name, address and occupation .
2 Date and time of accident.
3 Place where accident happened.
4 Cause and nature of injury.
5 Name and address and occupation of person giving notice, if other than the injured person. -
What is their name?
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What is their address (including post code)
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What is their phone number
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Job title
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Was the injured person (please tick one box)
About the person filling out this form
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If this form is being filled out by any one other that the injured person , please complete this section
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Is this form being completed by any one else other than the injured person
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What is their name
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What is their address (including the post code)
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What is their contact telephone number
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What is their occupation
About the accident
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When did the accident happen (include the date and the time of the accident)
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Location of injury
- Head
- face/neck
- Eye
- Chest
- Abdomen
- Back
- Arm / shoulder
- Wrist
- Hand
- Finger
- Leg / Hip
- Ankle
- Foot
- Respiratory system
- Digestive system
- Other
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Please state
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What type of injury
- Amputation
- Bruising / swelling
- Dislocation
- Electric shock
- Strain / sprain
- Asphyxiation / gassing
- Loss of consciousness
- Cut / Laceration / abrasion
- Foreign body
- Fracture
- Burn / scald
- Whiplash
- Shock / concussion
- puncture
- Ill health
- Crush
- Ingestion
- Internal
- Other
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Please state
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Were did the accident happen ( select area)
- WELD SHOP
- PRESS SHOP
- TOP PRESS SHOP
- EARTH MOVER
- PAINT PLANT
- MAINTENACE
- TOOL ROOM / FAB SHOP/ TEST CENTRE
- OLD SPIECAL WHEELS
- DESPATCH
- YARD
- POWDER COAT
- STORES
- OFFICE
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What Location (machine number, process area, etc.)
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Give details of how the accident happened
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Was a first aider required / present
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Name of first aider
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Treatment given
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Please sign to state that you have declined to attend hospital
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HOSPITALISATION FROM
Security will need to be informed if the injured person is being taken to hospital and the following details provided via e -mail to Security@titansteelwheels.com -
Name of injured person
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Department
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Clock Number
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Hospital Location
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Time Sent
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Time Returned
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Drivers Name
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The injured person Please sign and date
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Select date
For injured person only
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By ticking this box I give my consent to my employee to disclose my personal information and details of the accident which appear on this form to safety representatives and representatives of employee safety for them to carry out the health and safety functions given to them by law.
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Please print and sign your name.
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Select date
