QUESTION 4 CONTINUED 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
