NEILSON CARPET FACTORY
    ACCIDENT REPORT FORM
    THIS FORM MUST VE COMPLETED IN CAPITALS BY THE PERSON REPORTING THE 　ACCIDENT ON THE DAY OF THE ACCIDENT
    FULL NAME OF INJURED PERSON ___________________________________________
    TITLE (MR/MRS/MISS/MS) ___________________________________________
    HOME ADDRESS ___________________________________________
    __________________________________________
    __________________________________________
    STATUS OF INJURED PERSON __________________________________________
    DATE OF ACCIDENT __________________________________________
    TIME OF ACCIDENT __________________________________________
    LOCATION OF ACCIENT __________________________________________
    DETAILS OF INJURY __________________________________________
    CAUSE OF ACCIDENT _________________________________________ (HOW DID IT HAPPEN?)
    __________________________________________
    __________________________________________
    TAKEN TO HOSPITAL YES [] BY AMBULANCE [] BY CAR []
    (Please tick) NO []
    DO YOU CONSIDER THE COMPANY IS AT FAULT? YES/NO(delete which does not apply)
    IF 'YES’ GIVE REASON _________________________________________
    __________________________________________
    ACCIDENT REPORTED BY __________________________________________
    COMPANY STATUS __________________________________________
    DATE SIGNATURE