1. About the Person who had the Accident

  • Full Name:

  • Category of person

  • Job Title

  • Address:

  • Post Code:

  • Age:

  • 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

  • PPE

  • Tools or Equipment

  • Caused by 3rd Person

7. Signatures

  • Signature of Person Completing Form

  • Date:

  • Signature of Injured Person (or Parent / Guardian if Under 16):

  • Date:

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

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