Form No: TSL SAF

020
Injured Persons Report Issue No: 01
Issue Date: 25/05/07
Page 1 of 2

To be completed by the Injured Person, or by someone on their behalf. Tick boxes where appropriate.
Complete all Sections. Use block letters. More copies of this form can be obtained from the HSE Manager –
Rupert Guthrie.

Surname Forenames

Grade Local Office

National Ins No. Payroll Number

Date of Accident Time of Accident hrs

Exact Location of Accident

Part of body affected

Nature of injury/ill health

Full description of what happened

/cont. overleaf if necessary

If Road vehicle involved – Give registration number

Was First Aid given? Yes By whom

No

Did you attend hospital? Yes If yes, were you detained in hospital more than 24 hrs Yes
No No

Did you / will you be off Yes If yes, how many days do * you
work due to this accident? No expect to be Off Work
* Give your best guess as to the number of days off work. Only enter the Date returned to work if known.

Date of first day off Date returned to work

Give names of persons who witnessed the accident happen

To whom did you first mention the accident?

When did you do so? Time hrs Date

To whom did you report the incident? (Site Manager)

When did you do so? Time hrs Date

Rostered hours on day of incident from hrs to hrs

Your Signature Date

 Form No: TSL SAF
020
Injured Persons Report Issue No: 01
Issue Date: 25/05/07
Page 2 of 2

Send this form to the TSL EHS Manager. Ensure that you, or someone on your behalf, fills in the Accident
Book.