Version: V.2.2. (2021)
Date: 04/01/2021
Ref: HALSO-HS-01
SER. NO
HAL-HS-01 | ACCIDENT/INCIDENT FORM
Personal Details (Please print)
Surname:
Employee ID:
Forename(s):
DOB:
Home
Address:
Contact No:
Email:
Gender:
Job Title:
Incident Description
Location:
Department:
Date:
Time:
Incident Description [Describe what caused the incident/accident/injury, what you were doing
just before the incident and what you did after the incident.]
Were you performing regular duties at the time of the
incident?
Did anyone witness the incident?
If YES, please list their names.
Yes
No
Yes
No
Version: V.2.2. (2021)
Date: 04/01/2021
Ref: HALSO-HS-01
Statement of Events (What happened, who was involved, witnesses etc)
Cause (– Identify the primary cause, i.e. he/she fell, and/or contributing factors of the accident)
Remedial Actions (What has been done to prevent this type of incident happening again? (e.g. additional
training, supervision, discipline, equipment or policy changes)
Action
Actioned by date:
Declaration: I confirm that the above information is correct to the best of my knowledge and recollection
INJURED PARTY / WITNESS (delete as appropriate)
Signature:
Date: Click here to enter a date.
Contact Number:
Email:
Investigation Coordinator (or person nominated to take witness statement)
Name:
Role:
Signature:
Date: Click here to enter a date.
Version: V.2.2. (2021)
Date: 04/01/2021
Ref: HALSO-HS-01