Sender Information

Report of an accident or case of occupational ill-health

1. Date of accident     2. Injured persons - Dept/Section/Hall3. Personal details:

Name of injured or ill person

Category of person (Staff):(tick one box)

4. Description and severity of injury/ illness

e.g.  fracture, cut finger, dermatitis, and location – state L/R:

Severity (tick appropriate box):

5. Treatment

6. Details of accident

On the day of the accident between what hours was the injured person expected to work?

I hereby allow/do not allow (delete as appropriate) a copy of the information contained within this report to be
communicated to a third party, including line management and official Trade Union representatives