ACCIDENT, INCIDENTS & INJURIES REPORTING FORM

Person completing the form

Name

About the incident - please complete all details in full

Name of the person involved
Private Address
Status
Gender

Incident Details

MM slash DD slash YYYY
Normal place of work / project / location. If a non employee state reason for being present and give employers details if applicable

Witness Details (if applicable)

Name
Status
Give a full account of the incident, accident or injury (e.g. explain how it happened; what the person was doing at the time; what was said; whether alcohol/drugs were involved; threat or use of weapons; verbal threat to member of staff; if a fall from height state the height; where property is damaged give value and details of property). Also include details on what could have happened. Provide a sketch where necessary (separate paper sheet)

Further details

If yes give brief details
If yes please give brief details
 
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