Accident Photos Man Pictures of Honey Singh Graphic Image Clipart of Gopinath Munde Car Prone Photos: Accident Report Form Accident Photos Man Pictures of Honey Singh Graphic Image Clipart of Gopinath Munde Car Prone Photos

Monday 14 July 2014

Accident Report Form Accident Photos Man Pictures of Honey Singh Graphic Image Clipart of Gopinath Munde Car Prone Photos

Accident Report Form Biography:

Source:- Google.com.pk
ACCIDENT/INCIDENT CLAIM FORM
Date of incident: _______________ Time: ________ AM/PM
Name of injured person:
Address:
Phone Number(s):
Date of birth: ________________ Male ______ Female _______
Who was injured person?(circle one) Passenger System Employee
Type of injury:
Details of incident:
Injury requires physician/hospital visit? Yes ___ No _____
Name of physician/hospital:
Address:
Physician/hospital phone number:

Signature of injured party _________________________________________________________
Date
No medical attention was desired and/or required.

Signature of injured party Date

Return this form to Safety Coordinator within 24 hours of accident.

THIS FORM MUST BE COMPLETED FOR ANY INJURY, WORK RELATED ILL HEALTH, DANGEROUS OCCURRENCE
AND NEAR MISS IN RESPECT OF STAFF, STUDENTS, CONTRACTORS AND VISITORS
GUIDANCE
• Please complete the form in BLACK INK and in BLOCK CAPITALS.
• If you have any queries when completing this document, please ask you departmental manager for advice
or contact the Health and Safety Unit on extension number 3317.
• A copy of the completed form must be passed on to the Health & Safety Unit as soon as possible.
• Keep a copy for your own record.
TO BE COMPLETED BY INJURED PERSON (IP) OR REPRESENTATIVE
SECTION 1 PERSONAL DETAILS
GUIDANCE
SECTIONS 1, 2 and 3 to be completed by the injured person where possible.
Alternately a representative or manager may do so on their behalf.
Dangerous Work related
Accident Occurrence ill health Near Miss
Full Name:
Title: Prof Dr Mr Mrs Ms
Home Address:
Job/Course Title:
Status Staff Student Contractor Visitor
Please Tick:
Please tick as
appropriate:
Accident Report Form
University Contact Number
PostcodeSECTION 2 ACCIDENT RECORD
GUIDANCE
This section concerns details of the injury, work related ill health, dangerous occurrence or near miss.
Please be as specific as possible with regard to location (address, postcode, room number etc), and type of injury.
If a major injury or dangerous occurrence has occurred please contact the Health & Safety Unit as soon as possible.
When did it happen?
Date of occurrence
Where did it happen?
(state which room, bldg. or place)
How did it happen?
Give the cause if you can.
Was there an injury?
If so please give details
(e.g. fracture, bruise, cut, sprain
strain)
If the person suffered work related
Ill health, please give details
SECTION 3 TREATMENT DETAIL
GUIDANCE
This section should be completed by a first aider or manager/supervisor in respect for all treatment whether
accepted or refused.
Accepted Refused Advised to attend Not Applicable
hospital /GP
Brief details of the First
Aid given:
First Aider’s name:
Was the injured person sent
to hospital:
Hospital Details:
Signature Signature of
of injured person: Representative:
Date:(DD/MM/YY)
If representative, please give your full name, relationship with the injured person and contact number.
Full Name: Contact
Tel Number:
Relationship:
Time of occurrence:
(Please use 24hr clock e.g. 0600)
DD / MM / YY Hrs : Mins
Yes No Yes No
DD / MM / YY Hrs : Mins
Was First Aid
Was the Injured Person in hospital
for more than 24 hours
DD / MM / PRELIMINARY INVESTIGATION SECTION
THE DEPARTMENTAL MANAGER/SUPERVISOR/LECTURER IN CHARGE MUST COMPLETE THIS SECTION.
SECTION 1 INVESTIGATOR DETAILS
GUIDANCE
To be completed by Manager/Supervisor/Lecturer. Please complete contact details in full.
Full Name: Title:
Faculty: Extension Number:
School/Dept.:
Division/Unit
SECTION 2 WITNESS DETAILS
GUIDANCE
Please ensure that names and appropriate contact details are taken from any witnesses present. If you feel that it is necessary
to add details of more than two witnesses please continue on a separate sheet and indicate that this is attached.
First Witness Address:
Name:
Contact Number:
Second Witness Address:
Name:
Contact Number:
SECTION 3 SAFETY MANAGEMENT CHECKLIST
GUIDANCE
Please ensure that all questions are answered and that copies of relevant documents are securely attached
to the report/investigation forms.
Was the area/work activity subject to
a risk assessment? Yes No
(If YES, please attach a copy)
Have you reviewed the risk assessment
in the light of the occurrence? Yes No
(If YES, please attach a copy)
Was Permit to Work/Access authorisation in effect
(If YES, please attach a copy) Yes NoAre there any departmental rules/safe systems Yes No
of work applicable to the area/work activity?
(If YES, please attach a copy)
Was personal protective equipment being used Yes No
at the time?
(If YES, indicate the type in the boxes below)
Eye Face Ear Hand Foot Respiratory Body
Has the injured person resumed work/study? Yes No
If yes,on what date? (DD/MM/YY)
SECTION 4 PRELIMINARY INVESTIGATION DETAILS
GUIDANCE
Please summarise accident/incident ‘cause and effect’ and action taken. Continue on a separate sheet if necessary.
Please send completed form to the Health and Safety Unit
SECTION 5
FOR USE BY HEALTH AND SAFETY UNIT
Received in Health & Ref No Date:
Safety Unit by:
F2508 required? Further investigation Referral to Insurance
required? Officer
DD / MM /
DD / MM /

Accident Report Form Accident Photos Man Pictures of Honey Singh Graphic Image Clipart of Gopinath Munde Car Prone Photos