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WHC-F-027 Accident Record

Please report any on-site accidents or dangerous occurrence to your supervisor or first aider and complete this form.

Remember - Certain accidents are reportable to the enforcing authorities so it is important that accidents are reported correctly.

Failure to report an accident correctly may result in disciplinary action.

1. About the person who had the accident

Name

Occupation

Address incl. Post Code

Contact Details

2. About you, the individual filling in this record

If you did not have the accident, write your name, address, contact details and occupation here:

Name

Occupation

Address incl. Post Code

Contact Details

3. Details of the accident

When did it happen?

Where did it happen?

How did the accident happen? Give the cause if possible.

If the person who had the accident suffered an injury, please give details.

I declare that all of the information I have provided is complete and accurate.

Your Signature

4. To be completed by Witley Homes Construction Management Only

Your submission has been received.

Complete this box if the accident is reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995.

How was the accident reported?

Who reported the accident?

Sign

Date

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