Information
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Reference ( site name / ED11 / date )
ED11: Accident Report Form
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1. About the person that had the accident
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Name
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Address
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Occupation
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2. About you the individual, filling out the form
(if you did not have the accident, write your address and occupation) -
Name
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Address
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Occupation
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3. Details of the accident
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When it happened
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Address of where it happened
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How did the accident happen? (give the cause if possible)
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If the person who had the accident suffered an injury, give details
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Sign the record and date it
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4. For the employer only
Complete this box if the accident is reportable under the Reporting of Injuries, Diseases and Dangerouos Occurences Regulations (RIDDOR) -
How was it reported?
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Sign and date
