1. Injured person details
About the person who had the accident
Name
*
Address
Postcode
Employment Status
*
Please Select
Employee
Contractor
Agency
Member of the public
Young person
Work placement
Visitor
Job Title
*
Site Location
*
Ashford
Dartford
Ipswich
Ipswich Van Centre
Norwich
Sittingbourne
Tonbridge
Thurrock Van
Thurrock Truck
Witham
Welham Green
2. Reported by
About you, the person filling out this record
Name
*
Address
Postcode
Job Title
*
E-mail
*
Date Reported
*
-
Day
-
Month
Year
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3. Accident Details
Accident Date
*
-
Day
-
Month
Year
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Accident Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Return to work date
-
Day
-
Month
Year
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RIDDOR Reportable?
Yes
No
Accident Location
*
Accident Type/Cause
*
Please Select
Fall from height
Manual handling
Slips and trips
Electrocution
Fire
Defective Equipment
Struck by fixed item
Struck by moving object
Struck by falling object
Struck by moving vehicle
Poor housekeeping
Lack of personal care
Operator error
Other
Accident Details (what happened?)
*
Witness details (if applicable)
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4. Injury and first aid
Injury Type
*
Please Select
Bruising
Cut
Abrasion/Graze
Swelling
Burn / Scald
Inflammation
Irritation
Laceration
Muscular
Sprain
Shock
Fracture
Dislocation
Fatality
Other
Part of the body affected
*
Please Select
Back
Face
Fingers
Head
Neck
Lower limbs
Torso
Left ankle
Left arm
Left ear
Left foot
Left hand
Left knee
Left leg
Left wrist
Left shoulder
Right ankle
Right arm
Right ear
Right foot
Right hand
Right knee
Right leg
Right wrist
Right shoulder
Other
First aid given?
*
Yes
No
If yes, give details
First aider Name
Hospital attended?
*
Please Select
Yes
No
If yes, which one?
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