Accident Record Book
1. About the person who had the accident:
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
*
2. About you, the person filling in this record:
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
*
3. About the Accident:
continue on the bottom of the form if you need to.....
Date/Time Occurred:
*
/
Day
/
Month
Year
Date
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:
Hour
00
10
20
30
40
50
Minutes
Say where it happened:
*
Room or Place Accident Occurred
Say how the accident happened:
*
Give the cause if you can?
State if Injured and where injured:
*
If no injuries, state NONE.
State any further information:
If NONE leave this blank.
Upload as many pictures possible of the scene of accident/incident:
*
Browse Files
Cancel
of
Signature
*
Date
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Day
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Month
Year
Date
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Hour
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Minutes
4. For the employee/injured 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 and representatives of employee safety for them to carry out the health and safety functions given to them by law.
Employee/Injured Signature
*
Date
/
Day
/
Month
Year
Date
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:
Hour
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01
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59
Minutes
5. For the employer only:
Complete this box if the accident is reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR). To report, go to page 4 of this book or go to www.hse.gov.uk/riddor/report.htm2.
How was it reported?
Date Reported:
-
Day
-
Month
Year
Date
Employer Signature:
Submit
Should be Empty: