Accident Form Accident Report Details Complete the form below to notify Head Office of any accidents. 1. About the person who had the accidentName:Address:Postcode:Occupation:2. About the person filling in the accident reportIf you did not have the accident, complete your name, address, postcode and occupation.Name:Address:Postcode:Occupation:3. About the accidentDate the accident happened :* 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 Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB, Max. files: 5. Please sign and date:Signature:Date: 4. For the employee onlyBy 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: 5. For the employer onlyComplete 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:
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