Where did the Incident Happen?
How did the Incident Happen / Cause (Give details of exactly what, how and why the incident happened):
Witness 1 Name
Witness 1 Contact Number
Details of Injury:
Notify Line Manager or Willen General Manager Immediately (as applicable)
First Aider Name:
Details of any First Aid / Treatment Given:
If Taken to A&E, which hospital?:
What are considered as contributory causes?
Insufficient Care taken by Employee
Tools or Equipment
Caused by 3rd Person
Name of Parent / Guardian - If Applicable (Print):