Accident/Disease/Dangerous Occurrences: Form ACC3

Investigation & Action Report

This Corporation

Accident Reference Number:                                     
 

Injured Person

Name

 

Age

 

years

Occupation

 

Length of Service:

 

years

        Employee         Trainee          Agency Worker        Contractor Visitor

        Other (please specify)                                                                 

Incident Details

Date:

 

Time:

 

Reported To:

 

Designation

 

Location of accident:

 

Details of witnesses to accident:

 

Explanation of how incident occurred:

 

 

 

Recommendation to prevent recurrence

Action recommended

 

 

Date of action

 

Accident Record Details

Yes

No

Recorded in accident book

Verbal notification if required to Enforcement Authority

Written notification if required to Enforcement Authority

Details of incident sent to insurance company

Accident investigated by:

Name (print):

                               

Position:

                               

Signature:

                               

Date:

                               

 

 

 

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This information is derived from the Health & Safety Manual and Kit
For further information about the Kit, visit The Essential Health and Safety Manual home page
 
  See also Health & Safety Made Easy
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