Accident Book

According to legal requirements for accident reporting and documentation

Project Information

Project Name:

Address:

City:

State:

ZIP Code:

Country:

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Accident Book

Keep this book where people can easily get to it.

For use at

Name of place

Address

PostCode

Name of person/office responsible for storing Accident Reports

Accident Form Register

Report Number	Date	Reported By	Accident Record sent to

Employee Duties.

When you are injured at work, the law says you have to tell your employer as soon as you can. You can do this by writing about your accident on this form. Anyone else can do this on your behalf.

How to use this form.

Complete the accident record, giving your personal details and details about your accident. Answer each question that applies to you. Do not complete section 4 called for the employer only.

When you have filled in the form, hand it to the person nominated as being responsible for storing the accident records. You may wish to make a photocopy of the form before handing it in. You should also keep a note of the report number.

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Accident Record

1 About the person who had the accident

Name

Address

PostCode

Occupation

2 About you, the person filling in this record

If you did not have the accident write your address and occupation

Name

Address

PostCode

Occupation

3 About the accident

Continue on the back of this form if you need to

Say when it happened.

Say where it happened. State which room or place.

Say how the accident happened. Give the cause if you can.

If the person who had the accident suffered an injury, say what it was.

Please sign the record and date it.

4 For the employer only

Complete this box if the accident is reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR)

How was it reported?

Date reported

Signature

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