F077 Accident Report

• Site conducted

  Select

• CBRL Number

• Site Name

• Accident Report Prepared By

• Date

  Date

Part 1: About You

• What is your full name?

• What is your job title?

• What is your telephone number?

• What is the name of your organisation?

• What is its address and postcode?

• What type of work does the organisation do?

Part 2: About The Accident

• On what date did the accident happen?

• At what time did the accident happen?

• Please provide as much detail as possible, including addresses and postcodes, block numbers, plot numbers and room locations wherever relevant.

• Where did the accident happen?

Part 3: About the Injured Person

• What is their full name?

• What is their home address and postcode?

• What is their telephone number?

• How old are they?

• Are they Male or Female?

  Male

  Female

• What is their job title?

• The injured person was

  Select A fatality A major injury or condition An injury to an employee or self-employed person which prevented them doing their normal work for more than 7 days An injury to a member of the public which meant they had to be taken from the scene of the accident to a hospital for treatment None of the above

  • A fatality
  • A major injury or condition
  • An injury to an employee or self-employed person which prevented them doing their normal work for more than 7 days
  • An injury to a member of the public which meant they had to be taken from the scene of the accident to a hospital for treatment
  • None of the above

• Where relevant, give details of the Injured Persons employer.

Part 4: About the Injury

• What was the injury? (eg. fracture, laceration)

• What part of the body was injured?

Part 5: About the Kind of Accident

• Please tick one of the boxes below which best describes what happened.

• Contact with moving machinery or material being machined

• Hit by a moving, flying or falling object

• Hit by a moving vehicle

• Hit by something fixed or stationary

• Injured while handling, lifting or carrying

• Slipped, tripped or fell on the same level

• Fell from a height

• Trapped by something collapsing

• Drowned or asphyxiated

• Exposed to, or in contact with, a harmful substance

• Exposed to fire

• Exposed to an explosion

• Contact with electricity or an electrical discharge

• Injured by an animal

• Physically assaulted by a person

• Another kind of accident

Part 6: Describing what Happened

• Give as much detail as you can, for instance, (i) the name of any substances involved; (ii) the name and type of any machine or plant involved; (iii) the events that led to the accident; (iv) the part played by other persons.

• If it was a personal injury, give details of what the person was doing. Describe any action that has since been taken to prevent a similar accident.

• Describe what happened

• Unsafe mechanical condition

• Steps to eliminate condition

• Unsafe action

• Steps to eliminate unsafe action

Part 7: Your Signature

• Your name (PRINT NAME)

• Your name (SIGN NAME)

  Sign