Introduction to Health and Safety at Work

Introduction to Health and Safety at Work
126
 
Appendix 8.1 Injury report form
INCIDENT/ACCIDENT REPORT
INJURED PERSON:........................................................... Date of Accident: / /20 Time.......... am/pm
POSITION:......................................................................... Place of Incident: .............................................................
DEPARTMENT:.................................................................. Details of Injury: ...............................................................
Investigation carried out by: .........................................................................................................................................
Position: ............................................................................ Estimated Absence: .........................................................
Brief details of Accident
(A detailed report together with diagrams, photographs and any witness statements 
should be attached where necessary. Please complete all details requested overleaf.)
Immediate Causes
Underlying Cause
Conclusions
(How can we prevent this kind of incident/accident occurring again?)
Action to be taken:
Completion 
Date: / /20
IMPORTANT
Please ensure that an accident investigation and report is completed and forwarded to Human Resources 
within
48 hours of the accident occurring
.
Remember that accidents involving major injuries or dangerous occurrences have to be notifi ed immediately by 
telephone to the HSE/Local authority.
Signature of manager making report: ............................................................................ Copies: Personnel Manager
Health and Safety Manager
Date: / /20 
Payroll 
Controller
INJURED PERSON: Surname ................................................................... Forenames ...............................................
Male/Female
Home address ........................................................................................................................................ Age .............
Employee 
䊐
Agency 
Temp 
䊐
Contractor 
䊐
Visitor 
䊐
Youth 
Trainee 
䊐

(Tick one box)

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