GC Fitout Incident Report Form

Project Name*

Email

Address: Home / Company*

Date of Birth*

Date of the accident*

The date of the accident reported*

Work being carried out when the accident occurred*

Full description of the equipment used, if any*

Witness 1 - Name*

Witness 1 - Company Name*

Witness 1 - Statement*

Witness 2 - Name

Witness 2 - Company Name

Witness 2 - Statement

Investigator Name*

Date*

Signature of person completing the form.