Accident Report Form

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Please use this form to report all injuries, diseases, ill-health and near misses.

Complete the form immediately after the incident or arrange for someone to do it on your behalf.

Note: A separate form must be completed for each person who is injured are a result of an accident.

What are you reporting? *

Accident

Incident

Near miss

Work related ill-health

Other:

When did it happen? *

YYYY

When did it happen? *

Time

Where did it happen? Please be as specific as possible giving location and room *

What happened?

Please describe the accident, incident, near miss, dangerous occurrence etc including the events leading up to it and details about any equipment, substances or materials involved.

What category best describes the incident? *

Witnesses

Please include names and contact details of anyone who witnessed the incident

Who was involved?

Name, role and contact details, including full address if volunteer or third-party (contractor, member of public etc)

What type of injury, illness or disease was sustained?

Please include which part/side of the body was affected.

What treatment was provided?

Please include whether first aid/or hospital treatment was needed.

Consent *

I am, or have checked with, the person involved in the accident and they are happy for the information on this form to be disclosed to safety representatives and representatives of employee safety when requested.

Required

Your details - If you are not the person involved in the accident, please give your name, address and contact details *

Submit

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