NEILSON CARPET FACTORY
ACCIDENT REPORT FORM
THIS FORM MUST VE COMPLETED IN CAPITALS BY THE PERSON REPORTING THE ACCIDENT ON THE DAY OF THE ACCIDENT
FULL NAME OF INJURED PERSON ___________________________________________
TITLE (MR/MRS/MISS/MS) ___________________________________________
HOME ADDRESS ___________________________________________
__________________________________________
__________________________________________
STATUS OF INJURED PERSON __________________________________________
DATE OF ACCIDENT __________________________________________
TIME OF ACCIDENT __________________________________________
LOCATION OF ACCIENT __________________________________________
DETAILS OF INJURY __________________________________________
CAUSE OF ACCIDENT _________________________________________ (HOW DID IT HAPPEN?)
__________________________________________
__________________________________________
TAKEN TO HOSPITAL YES [] BY AMBULANCE [] BY CAR []
(Please tick) NO []
DO YOU CONSIDER THE COMPANY IS AT FAULT? YES/NO(delete which does not apply)
IF 'YES’ GIVE REASON _________________________________________
__________________________________________
ACCIDENT REPORTED BY __________________________________________
COMPANY STATUS __________________________________________
DATE SIGNATURE |
