Accident Sheet

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Accident Record

• When did it happen?

  Date

• Where did it happen?

• How did it happen?

• Was there an injury?

• Evidence (of injury)

  Media

• Evidence (of accident)

  Media

Treatment Detail

• Was First Aid

  Accepted

  Refused

  Advised to attend hospital/GP

  Not Applicable

• Brief details of the First Aid Given:

• First Aider's name

• Was the injured person sent to hospital?

  Yes

  No

  N/A

• Was the injured person in hospital for more than 24 hours

  Yes

  No

  N/A

• Hospital details

• Signature of injured person:

  Sign

• Signature of representative:

  Sign

• Date

  Date

Representative (if applicable)

• Full Name

• Relationship

• Contact Telephone Number