QMF027

• Conducted on

  Date

• Prepared by

• Location
  Address

• An accident is an unplanned event that results in an injury or could have resulted in an injury or results in damage to equipment or property. Anyone can complete an accident report form. Once completed the form should be sent to the Health and Safety manager at Silverhills.

Details of any Injured Person

• Full Name

• Status

  Employee

  Subcontractor

  Visitor

• Address & Postcode if a Subcontractor or Visitor

• Telephone number &/ contact details

Details of accident / incident

• Date of occurrence

  Date

• Time of occurrence

  Date

• Location of occurrence

• What happened. Give cause (how & why) if known

• Photos if applicable

  Media

Nature of Injury

• Details of injury

• Treatment given

• Treatment given by

• Taken to hospital

  Yes

  No

  N/A

• Which hospital, & how were they taken

• Off work as a result of their injury

  Yes

  No

  N/A

• If Yes, for how many days

• Any further information

Environmental Conditions

• Weather

• Wind speed

• Any other remarks

• Photos if applicable

  Media

Details of person completing this report

• Full Name

• Status

  Employee

  Subcontractor

  Visitor

• Address & Postcode if a Subcontractor or Visitor

• Telephone number &/ contact details

• Signature

  Sign

• Date

  Date

For completion by the company Health and Safety Officer

• Accident / Incident investigated Yes / No

• Written investigation report necessary Yes / No

• Written investigation report completed Yes / No

• RIDDOR reportable Yes / No

• If Yes, date reported: