Connection Flooring Ltd. Henson Close, South Church Enterprise Park, Bishop Auckland. DL14 6WA
Personal Accident/Injury form
This form should be used to report a personal accident or injury where someone has been injured.
Time
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
Who is involved?
*
Employee
Member of the public
Agency
Contractor
What department do you work in?
Driver / Depot
Warehouse / Samples
Stores / Retail
Office Based
Member of public
Type of accident
Slip, trip, fall on same level
Handling, lifting or carrying
Struck by moving object
Act of violence
Fall from height
Machinery
Other
1. Details about the person who had the accident
Please complete all section.
Name.
*
Address inc postcode.
*
Contact telephone number.
*
Occupation and place of work.
*
2. Details about the person completing this form
The person completeing this form may or may not be the person directly involved in the incident.
Are you also the person involved in the incident
*
Yes
No
3. Person clompleting the form
Name..
*
Address including postcode..
*
Contact telephone number..
*
Occupation and place of work..
*
4. About the accident
MEANING: An accident is In general, an unplanned or unexpected event which occurs suddenly and causes injury or loss
Time of accident
*
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
Date of accident
*
-
Day
-
Month
Year
Date Picker Icon
Exact location of the accident eg: department, area
*
How did the accident happen? - include the cause
*
Details of any injuries suffered
Was any first aid required
*
Yes
No
Name of any witness
First Name
Last Name
Take a Photo of the location the accident took place
Take Photo of the physical injury if possible ie cuts, bruising etc
Take additional Photo you think are relevant
Give details of any treatment
*
5. Declaration
The information from this form will be kept as a record to allow the company to comply with the Health & Safety at Work Regulations 1974. All data will be collected, used and stored in line with GDPR. The use of advanced electronic signatures is in line with 'article 3' of eIDAS regulations.
E-signature of person completing this form
*
I confirm that the statement given is a true representation of the incident
Signature of injured person
*
Signature of person completing the form
Submit form
Should be Empty: