Accident reporting form Please complete it as soon as possible after the event, providing detailed and accurate information. Your report is crucial for maintaining safety, preventing future incidents and complying with regulations. A: Injured person detailsTitleFamily name(Required)Other namesGender(Required)Please select an optionMaleFemaleNon-binaryTransgenderIntersexI prefer not to sayDate of birth(Required) DD slash MM slash YYYY AddressJob title(Required)Project manager (if applicable)Line managerTelephone number(Required)Email(Required) Status(Required) Employed Piece worker Work experience Visitor Contractor Other Working pattern(Required) Full time Part time B: Accident detailsDate accident form completedDate of accident DD slash MM slash YYYY TimeAddress(Required)Location(Required)Activity at the time of incident(Required)Description of incident(Required)Nature & extent of injuries(Required)Treatment (tick all relevant boxes)(Required) None Self First Aider Occupational Health Service Own General Practitioner Hospital Absence(Required) Returned to work / studies after treatment Likely to be more than 3 days Not yet known C: AcceptanceAcceptance I, the undersigned, agree that this is an honest and true account of the accident described above.Name(Required) First Last Job titleDatePhoneEmail(Required) This form is to be used by the Investigation Officer, or person on site responsible for the casualty’s welfare, to conduct an investigation, which will involve an analysis of all the information available, physical (the scene of the incident), verbal (the accounts of witnesses) and written (risk assessments, procedures, instructions, job guides etc), to identify what went wrong and determine what steps must be taken to prevent the adverse event from happening again, initiating the escalation process as appropriate, to Management or the HR Department.Gathering the informationWhere, when and who?Where and when did the adverse event happen? Were there any witnesses?Who was injured / suffered ill health or was otherwise involved with the adverse event?How and what?How did the adverse event happen? Note any equipment involved.What activities were being carried out at the time?Was there anything unusual or different about the working conditions?Were there adequate safe working procedures and were they followed?Was the risk known? If so, was a Risk Assessment completed? (Please indicate details of the Risk Assessment & who conducted it)Who was injured / suffered ill health or was otherwise involved with the adverse event?Were the people involved competent and suitable?Was the safety equipment sufficient?What were the immediate, underlying and root causes?Outcome - next steps, key learnings, change to process, etc.Investigation outcome (tick all relevant boxes) Additional training required (competence, knowledge, skill and experience) Human / judgement error (slip or lapse of memory / knowledge base) Violation (rule breaking, gross misconduct and/or misconduct) Escalation (change to process and/or policy required) Occupational health service support (specialist advice / guidance required) None (no further action required) Select AllAs you selected 'violation', what is recommended?As you selected 'escalation', what is recommended?Additional commentsUploadsUse this section to upload any supporting images, witness statements or other relevant material.Upload files here Drop files here or Select files Max. file size: 20 MB. Person completing this final accident report formName(Required) First Last Job titleEmail(Required) Date