Accident / Incident Form

Date & Time Completed
Type Of Report
Details about the casualty / Person affected

Name

Address

Date Of Birth

If the casualty is under 18 then ensure parents are notified

Contact Number

Location Of Accident / Incident

Select Location Of Accident

Activity Taking Place

Injury Sustained, Description As To What Happened & First Aid Given
Injury Sustained

Were The Emergency Service Called

Crime Reference (If Applicable) - Write N/A If Not

Description As To What Happened

Please Mark Body Parts Affected (If Applicable)
Please Mark Pain Threshold (If Applicable)

First Aid Given / Witnesses / Outcome

Head Injury Form Completed?

First Aid Given By

I Confirm That I Am Satisfied With The First Aid Given And The Details Recorded Are Correct And Accurate. Name & Sign
Form Completed By & Signed
Post First Aid

What Items Were Used From The First Aid Kit

Has The First Aid Kit Been Restocked & Resealed

Managers Use Only

Was There Any Defects, Equipment Involved; If So Was It Defective?

Is CCTV Available, If So Has It Been Burnt?

Further Investigation Required?

Is The Incident RIDDOR Reportable?

Record RIDDOR Reference No.

Any Further Information Needed - Record N/A If Not

Managers Name & Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.