Name of Injured Person
- Fecal matter
- Blood contamination
Describe in detail
What part of the body was injured? Describe in detail
What was the nature of the injury? Describe in detail
Describe fully how the accident happened?
What was the person doing prior to the event?
What caused the incident?
Were safety regulations in place and used?
What was wrong?
Recommended preventive action to take in the future to prevent reoccurence
Were there any witnesses?
Enter witness name
Person went to doctor/ hospital?
Police were called to the scene
Police reference number