Accident Report Form

SECTION 1

Company/Organisation details.

Name of Company/Organisation

Address of company/organisation

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Name of Supervisor

(in attendance when accident occurred)

Name of accident reporter *

Contact number

Job Title

(in attendance when accident occurred)

Job Title

Email address *

SECTION 2

Person affected by the accident

Name *

Person Involved in Incident

Date of birth *

Position of Person

(e.g. employee, external visitor, student)

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Contact number

SECTION 2A

Parent / Carer of the person affected by the accident*

•Complete only if the person affected by the accident is only 18 years old

Parent / carer name

Contact number

Parent or carer notified?

Address of parent / carer

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

SECTION 3

Accident Details

Date of accident

Time of accident

Location of accident

Description of accident

(e.g. what happened? why do you think it happened? was any equipment involved? were other people involved?)

Full name and address(es) of witness(es)

Name

First

Last

Address

Name

First

Last

Address (copy)

Name

First

Last

Address (copy) (copy)

SECTION 4

Injury and treatment details

Description of injuries sustained

If Yes - What treatment did they receive and who administered it?

If Yes - What treatment did they receive?

If applicable, how long did the casualty have to spend in hospital?

Any further action required?

Accident Report Form

SECTION 1

Company/Organisation details.

SECTION 2

Person affected by the accident

SECTION 2A

Parent / Carer of the person affected by the accident*

SECTION 3

Accident Details

Full name and address(es) of witness(es)

SECTION 4

Injury and treatment details

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