Accident / Incident Form

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Section 1: Information about person involved in the accident / incident

First Name *
Last Name *
Post Code *
Please indicate if *
Please indicate if (Other)
Date of Incident
Time of Incident

Section 2: Information about the location of the incident and treatment

Where did the incident take place? *
Where did the incident take place? (Other)
Details of Injury *
If in public, please state area
Was the person treated in hospital? *
If yes, which hospital?

Section 3: A description of the incident

Please provide details on the incident / accident *
What happened? How did it happen? What did you do?
Whom was the incident reported to? *
Did you contact family? Office? Police?

Section 4: Report

Has the incident been reported to the Police and/or Council? *
Please Provide details *
If no, why? *
Has the accident been classes as "reportable" as required by RIDDOR regulation? *
Has NOK been informed? *
Actions to be take? *
Actions to be take? (Other)
Additional Information *
Name of individual completing the form *
Date *

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