Accident Report Form
Connection Flooring Ltd. The Offices, The Future Business Park, Shildon. DL4 2RB
Who is involved?
Member of the public
1. Details about the person who had the accident
Please complete all section.
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
3. Person clompleting the form
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
Date of accident
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
Give details of any treatment
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
Should be Empty: