Information

  • Civil Contract audit been carried out on

  • Company Name

  • Date and time Accident / Incident was reported.

  • Location of Accident / Incident
  • Reported By

  • Build Area

Accident / Incident Details

PERSON(S) INVOLOVED

  • Name (Person 1):

  • Sex:

  • D.O.B

  • Address Details

  • Phone number

  • Do you require to complete a 2nd person injury

  • Name of Person 2

  • Sex:

  • D.O.B

  • Address Details

  • Phone number

  • Type of Accident

  • Name of other person involved

  • Third Party Contact Details

  • Third Party Address Details

  • Third party Insurance Details if at Hand

  • Photographes of damage.

  • Vehicle Reg:

  • Make/Model:

  • Age:

  • Enviroment

  • Ground Conditions

  • Equipment / Processes

  • Was there any witness(es)? If yes, provide name(s).

  • Please supply a name and contact number.

NATURE OF Accident / Incident

  • Type Of Accident / Incident

  • Describe the advents leading up to the accident / Incident taking place.

  • Detail any first-aid or medical treatment administered.

  • Photographs of Accident / Incident scene .

  • Detailed description of Accident / incident.

Qualification and on site Risk Assessment Evidence

  • Please take Photo of Risk ass and any qualification if applicable.

  • TIME AND DATE COMPLETED

  • Signature

  • PLEASE CONFIRM YES ONCE COMPLETED

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.