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