1. About the Person who had the Accident

Full Name:

Category of person

Job Title


Post Code:


Telephone Number

2. About the Person Completing this Form

Full Name

Job Title

Date Form Completed
3.Type of Incident
Select the incident type
4. About the Incident
Date of Incident:

Where did the Incident Happen?

How did the Incident Happen / Cause (Give details of exactly what, how and why the incident happened):

Were there any witnesses?

Witness 1 Name

Witness 1 Contact Number

5. About any Injuries & Treatment

Details of Injury:

Part of Body:
Are the injuries serious (Life Threatening or Loss of Limb)?:

Notify Line Manager or Willen General Manager Immediately (as applicable)

Treatment Required:

First Aider Name:

Details of any First Aid / Treatment Given:

If Taken to A&E, which hospital?:

6. Causes

What are considered as contributory causes?

Inadequate Training

Insufficient Care taken by Employee

Poor Housekeeping


Tools or Equipment

Caused by 3rd Person

7. Signatures
Signature of Person Completing Form
Signature of Injured Person (or Parent / Guardian if Under 16):

Name of Parent / Guardian - If Applicable (Print):

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.