School of Food Science and Environmental Health

Module Code and Title: TFSH1002

Sara Boyd
Lecturer:

Experiment Title: Accident Report Form

Submission Date:
22.04.2020

Student name(s) and number:

Olga Ciudin C19757639

Course Code: DT425 – Year One.

ACCIDENT REPORT FORM

 Date of report
 Name of the person involved in the accident
 Job title
 Supervisor name
 Has your supervisor been made aware of this incident?
 Date and time of Alleged Incident:
 Location of incident:
 Grade of accident
 Minor
 Moderate
 Severe
 Incident description: Describe tasks being performed and sequence of events
 Nature of injury:
 Actions taken to minimize injury:
 Details for any witnesses ( name and address) in case of moderate or severe cases
 Was the person authorised to be in that place at that time, for the purpose of work?
 What was the person doing at the accident?
 Was this something done for the purpose of his/her work?
 To whom was it first reported?
 When it was first reported?
 Was medical treatment necessary? If yes, name Hospital/Physician.

Employee signature Date Supervisor signature Date