Accident/Injury Report Form

Accident Report Form

Connection Flooring Ltd. The Offices, The Future Business Park, Shildon. DL4 2RB
Who is involved? *

Employee Member of the public
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 *

: Hour Minutes 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
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 *

Clear
Signature of person completing the form

Clear
Should be Empty:

Accident Report Form

1. Details about the person who had the accident

2. Details about the person completing this form

3. Person clompleting the form

4. About the accident

5. Declaration