Title Page
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Incident Form Number
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Which department/area did the incident take place?
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Completed By:
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Incident Form Opened:
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Name of injured persons
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Injured person's position/role
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Is the injured person employed by Tapeswitch
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Injured person's address
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Injured person's contact number
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Were there any witnesses
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Witness Name/s (Please include contact details if the witness/s are not employed by Tapeswitch)
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Date and time of accident
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Details of injury (Add photos if Injured Person will allow photos to be taken)
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Details of the incident (What, where, when, who and why) (Include photos of the area and any equipment involved)
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What equipment was involved (Take photos and include any evidence of damage)
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What medical treatment was given
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Who provided the medical treatment
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Injured Persons Signature (I confirm that the above details are accurate and if photos have been taken of the injury, that I gave permission for these to be taken)
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Date and Time Injured Person Signed Form
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Report completed by
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Date and Time Form Compelted
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Please report this accident to the Health & Safety Co-ordinator as soon as this accident form has been completed.
