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