Accident/incident

report form
Employee name:
John Hopkins
Employee position:
Student
Location of accident:
IT office/M1
Date/time of Accident:
15/2/16
Severity of incident:
Minor
Accident reported to:
Mr. Lance
Nature of Injury:
scrape
Eye-witnesses:
Lachy

Account of Accident:
John was opening a box and
scraped his lower arm on a opened
Tower shell
Cause of Accident:
PC equipment left in the open
Description of Injuries:
Minor scrape on lower arm
Steps taken to prevent accident
reoccurring:
Cleaned up tables

Personal details of reporter:

Lachy Rees, 16, Student