Accident Record

Accident Record

Contains public sector information published by the Health & Safety Executive and licensed under the Open Government Licence v1.0. Note: Items marked with an asterisk have to be completed. Click the section to expand and complete it.

About the person who had the accident
Name *

First Name Last Name

Address *

Address Line 1
Address Line 2
City	County
Post code	Country

Occupation *

About you, the person filling in the form
Tick if appropriate

Tick if you are the person who had the accident to copy the details from the previous section.
Name *

First Name Last Name

Address *

Address Line 1
Address Line 2
City	County
Postcode	Country

Occupation *

About the accident
Date *

- Day - Month Year
Time *

: Hour Minutes
Say where it happened, room or place *
If the person who had the accident suffered an injury say what it was *
Say how the accident happened, give the cause if you can *
Upload picture of the scene or injury (if available)

Consent
By ticking this box I give my consent to disclose my personal details of the accident which appear on this form to safety representatives and representatives of employee safety for them to carry out health and safety functions given to them by law *

I give my consent
Signature *
Date *

- Day - Month Year

Send the accident record
Send to the company where you had the accident. If you'd also like a copy give your own email address below:
Company E-mail *
Your email (option)
Should be Empty: