Accident Form – Dyson Farming

Accident Report Details

Complete the form below to notify Head Office of any accidents.

1. About the person who had the accident
Name:
Address:
Postcode:
Occupation:
2. About the person filling in the accident report
If you did not have the accident, complete your name, address, postcode and occupation.
Name:
Address:
Postcode:
Occupation:
3. About the accident
Date the accident happened :*
DD slash MM slash YYYY
Time the accident happened:*
Where did the accident happen (state the room or place):*
How did the accident happen. Give the cause if you can:*
If the person suffered an injury, state what it was:
If you have any photos upload them here:
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB, Max. files: 5.
Please sign and date:
Signature:
Date:
DD slash MM slash YYYY
4. For the employee only
By ticking this box I give my consent to my employer to disclose my personal information and details of the incident which appear on this form to safety representatives and representatives of employee safety for them to carry out the health and safety functions given to them by law:*
- I confirm consent to the above
Signature:
Date:
DD slash MM slash YYYY
5. For the employer only
Complete this box if the incident is reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR). To report go to www.hse.gov.uk/riddor/
How was the accident reported?
Signature:
Date reported:
DD slash MM slash YYYY