HTML Preview Injury Incident Form page number 1.
ACCIDENT / INCIDENT REPORT FORM
Note:
This form should be completed whenever an accident or incident occurs which results in injury or damage to
personnel or property.
If personnel or property WERE NOT injured or damaged during the Accident/ Incident, do not use this form.
Use the NEAR MISS REPORT FORM.
Accident / Incident Report Form
i
Name of person involved in
Accident/Incident:
ii
Address:
Phone:
iii
Who was involved in the Accident/Incident:
Student Employee Public Contractor Visitor
iv
Occupation:
v
If an employee of the Institute please state Department:
vi
If no, please elaborate:
vii
Particulars of Accident/Incident & circumstances under which the Accident/Incident occurred:
Use additional pages and/or photos if necessary.
viii
Place:
ix
Time:
Date:
x
Witness Phone No & Address:
Witness Phone No & Address:
xi
When and to whom was the Accident/Incident initially reported?