Accident Record Form
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1ACCIDENT RECORD FORM
Report No
1
ABOUT THE PERSON WHO HAD THE ACCIDENT
Name
Address
City/Town
Postcode
Telephone
Occupation
2
DETAILS OF PERSON REPORTING THIS ACCIDENT
Name
Address
City/Town
Postcode
Telephone
Occupation
3
DETAILS OF ACCIDENT/INJURY
Date:
Time:
DD
MM
YYYY
HH
MM
Where did the accident/injury take place?
Say how the accident happened, give a cause if you can
Details of accident/injury
Signed:
Date:
DD
MM
YYYY
4
EMPLOYERS USE ONLY
If this incident is reportable under RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995)
How was it reported?
Signed:
Date:
DD
MM
YYYY
Please Note: To comply with the Data Protection Act 1998 (DPA) personal details entered on accident record forms must be kept confidential.
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