FORMS ‘This space to fled OFFICIAL EDITION inby the Inspector ‘OCCUPATIONAL SAFETY AND HEALTH ACT orm prescribed by the Minister for Notie of Accident ‘Toe sent (iemesitely onthe seident becoming reported) io the Inspector 1, Name of Occupier 2. Adress of works where accident happened 3. Nature of Industry... ; 4, Branch of Department and exact place where the accident happened 5. Injured person's name (in Fll), 6, Address 6.(0) Sex, (0) ABE (ast inh) and (e) Occupation (8)... non ©. 1. Date and hour of cede. 8. Hourat hich hth stared wer on day of cient. 9. Cause or nature of szldent (6) teamed by machinery — (© Givename ofthe machine and part saingaccident (0) (i) State whether it as moved by mechanical power sthesime (i) (6) State exactly ha inured person vas doing a he time © 10, Deserted briely nature nd entent of Injures (Stl, loss of finger, facture of ey, sea le) 11 Ifthe accident isnot ata, state whether injured person was disabled for more than tree days Stor earing full wages atthe \work which hele was employed. 12, Hae the accident been entered in General Register” Date Signature of Occupier, Manager or Agent