Page 68 - Online introduction to health and safetyl 2020_Neat

Accident Injured person information:

report form Name of injured
Person:

Address:

Date of birth:

Gender: Male / Female

Accident information
Date of accident: Time of accident:

Date reported: Time reported:

Accident reported by
who:

Location of accident:

Details of injury:

In the event of an accident, the following
procedure should be followed
Nature and how accident
• Fill in 2 copies of the Accident happened:
reporting form for ALL accidents.
• Contact parents/guardians.
• One copy of form to incident Did anyone witness the Yes / No
book/folder.
• Forward 1 copy to designated accident: (If Yes, state witness name/s and details below)
person for record keeping/action
required. Name of witnesses:
• Contact emergency services/GP
if required. First aid involved:
• Record in detail all facts (please provide details)
surrounding the accident,
witness's etc. Third Parties notified: Yes / No
• Any further action.
(If Yes, by whom and when below)
Third Parties notified by
CONTACT whom and when:
Recommended action to
COMPANY NAME be taken:

Signature:
PHONE:
Print name:

WEBSITE:

EMAIL: