ACCIDENT REPORT BOOK - HR, Health and Safety, … … · Web viewBy ticking this box, I give my...

ACCIDENT REPORT BOOK

1. About the person who had the accident:

Name:

Address:

Postcode:

Occupation:

2. About you the person filling in this record:

Complete if you did not have the accident:

Name:

Address:

Postcode:

Occupation:

3. About the accident:

Say when it happened:

Date: Time:

Say where it happened (which room or place):

Say how it happened (include the cause if you can):

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Say if the person who had the accident suffered any injury:

Please sign and date:

Sign: 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 to carry out the health and safety functions given to them by law.

Sign: Date:

5. For the employer:

Complete this box, if the accident is reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR).

How was it reported?

Sign: Date:

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Name:

Address:

Postcode:

Occupation:



Name:

Address:

Postcode:

Occupation:



Date: Time:



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Sign: Date:



Sign: Date:




Sign: Date:

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Name:

Address:

Postcode:

Occupation:



Name:

Address:

Postcode:

Occupation:



Date: Time:



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Sign: Date:



Sign: Date:




Sign: Date:

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Name:

Address:

Postcode:

Occupation:



Name:

Address:

Postcode:

Occupation:



Date: Time:



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Sign: Date:



Sign: Date:




Sign: Date:

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Name:

Address:

Postcode:

Occupation:



Name:

Address:

Postcode:

Occupation:



Date: Time:



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Sign: Date:



Sign: Date:


Complete this box if the accident is reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR).


Sign: Date:

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Name:

Address:

Postcode:

Occupation:



Name:

Address:

Postcode:

Occupation:



Date: Time:



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Sign: Date:



Sign: Date:




Sign: Date:

18




Name:

Address:

Postcode:

Occupation:



Name:

Address:

Postcode:

Occupation:



Date: Time:



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Sign: Date:



Sign: Date:




Sign: Date:

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Name:

Address:

Postcode:

Occupation:



Name:

Address:

Postcode:

Occupation:



Date: Time:



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Sign: Date:



Sign: Date:




Sign: Date:

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Name:

Address:

Postcode:

Occupation:



Name:

Address:

Postcode:

Occupation:



Date: Time:



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Sign: Date:



Sign: Date:




Sign: Date:

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Name:

Address:

Postcode:

Occupation:



Name:

Address:

Postcode:

Occupation:



Date: Time:



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Sign: Date:



Sign: Date:




Sign: Date:

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ACCIDENT REPORT BOOK - HR, Health and Safety, … … · Web viewBy ticking this box, I give my...

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