Title Page
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Site conducted
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Name of Injured Peson
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Address and Post Code:
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Telephone Number:
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Date of Birth
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Age:
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Gender
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Job Title & Duties
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The injured person is:
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Date & Time of the Incident
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What was the Injury:
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What Part of the Body was Injured?
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Site Location & Postcode
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Location of Accident on Site
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Was first aid treatment given
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By whom
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What first aid treatment was given?
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Did the injured person go to hospital?
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Which Hospital
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Was the injured person admitted to hospital
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Did the injured person return to work
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Is absence from work likely?
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Date of first day of absence
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Will this be for more than 3 days?
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More than 7 days?
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What PPE was being worn at the time of the accident
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How did the accident happen: It is imperative that photographs of the accident site are taken.
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Were there any witnesses?
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How many?
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Name of witness & Address
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Name of witness & address
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Name of witness & address
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What would prevent a recurrence of the accident?
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Name and occupation of person completing this form:
Witness Statement
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Name
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Age
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Address
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Date
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Statement
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Person making statment
