staff_health safety_incident_report | EzyStream

< Health & Safety

Incident Report

Had an accident? We need to know about it. Please describe your accident here.

Name

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Email

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Today's Date

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Date of incident or injury

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Time of incident or injury

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Did the injury occur at work?

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What is the location where the incident or injury occured?

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Did you receive an injury?

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If injured, what part of the body was effected?

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Other body part details (if applicable)

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If injured, what type of injury was sustained?

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If injured, how did the injury occur?

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Other details

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If injured, what was the agency of injury?

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Other details

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If injured, what treatment was received?

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Declaration: I confirm the above report provides a true, accurate and complete account of the incident or injury.

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Address

Thanks, your incident has been logged. Our team will be in touch with you.

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