Page 69 - Online introduction to health and safetyl 2020_Neat

Details of injury:

Nature and how
accident happened:

Did anyone witness the Yes / No
accident:
(If Yes, state witness name/s and details below)
Name of witnesses:

First aid involved:
(please provide details)

Third Parties notified: Yes / No

(If Yes, by whom and when below)
Third Parties notified
by whom and when:
Recommended action
to be taken:

Additional Information
CONTACT

COMPANY NAME

PHONE:

WEBSITE:

EMAIL:

Countersigned by
injured party or their
representative.
Print name:

If countersigned
relationship to injured
party