Vindex Systems Accident Record Report VIN.Q.321

Site Details and Job Information

• Site Address
  Address

• Client / Site

• Job Title_QVIN

• Conducted on

  Date

• Who has had the accident?

• Prepared by

1. Information about the person who has had the accident.

• Name

• Address
  Address

• Occupation

2. Information about you filling out this record.

• Name

• Address
  Address

• Occupation

3. Information about the accident.

• When did the accident happen.

  Date

• Where did the accident happen. State which Room, area or place etc.

• How did the accident happen? Give the cause of the accident if possible.

• Has the person suffered any injury, if so what are the injuries?

• Reportee Signature

  Sign

• Date

  Date

4. For the employee only

• By ticking this box I give my consent to my employer to disclose my personal information and details of the accident which appear on this form to safety representatives of the employee safety team for them to carry out the health and safety functions given to them by law.

• Employee Signature

  Sign

5. For the employer only

• Complete this box if the accident is reported under the Reporting of injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR). How was the accident reported?

• Date reported

  Date

• Signature

  Sign