Accident Form | Specialist Recruitment Hamilton

Candidate details

Name*

First Last

Address*

Address2

Gender*

Male
Female

Date of birth*

Work details

Place of work*

Length of employment (weeks/months)*

Accident (A) and Incident (I) information

Date of A/I*

Time of A/I*

:

Location*

Date reported*

Accident and Incident details

Type of injury (please tick)*

Other (please specify)

Injured part of the body*

Left
Right
No Injury

Description of what happened*

What caused the accident/incident to occur?*

Type of accident/incident?*

Near miss
Illness
Injury

Severity of the accident/incident? (please tick)*

Minor
Serious
Moderate
Very serious

Treatment details

What treatment was given? (please tick)*

None
Doctor/Hospital
First Aid

Other (please specify)

Accident/Incident investigated by?

Name*

First Last

Date*

WorkSafe

Does WorkSafe need to be notified?*

Yes
No

If yes, please provide details (who did you speak to, date, outcome etc)

What action has, or will, be taken to stop another accident/incident of this nature reoccurring?

Action and when?*

Date completed*

Accident/Incident report

Incident

Our services

Temporary

Permanent

Executive

Industrial