Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Select date
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Name
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Address
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Tel number
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Position
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Site
Descriptions of Accident
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Location of Accident.
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Time of Accident
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Date of accident
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Time reported
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Date reported
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Describe what took place
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Describe injury
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Draw place on body
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If Accident proved fatal or major the H.S.E. MUST BE INFORMED IMMEDIATELY.
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Date HSE INFORMED.
Medical attention given
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First aid given by
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Ambulance called
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Taken to hospital
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Admitted
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Doctor/clinic called
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Released
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Hospital/doctor name
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Details of immediate medical action
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If no medical attention was given explain why.
Witnesses
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Name
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Address
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Name
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Address
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Name
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Address
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Select date
Other information
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Male
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Female
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National insurance number
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Add signature
