ACCIDENT REPORT FORM

Details of person completing this report

Full name:
Staff/Student/Visitor/Contractor (circle relevant category)
School/Department/Course if staff or student UTHM
Address & postcode if visitor or contractor

UTHM & 86400

Telephone contact number 017-7902703

Signature

Date 13 September 2015

Details of accident:
What happened. Give cause (how and why) if known He was fell down repaired the LCD
projector because the condition of ladder is not good and the technician was careless while
stepping up the ladder.
When it happened:

date: 2013

time:

Where it happened: G3 class

Details of victim/any persons injured
Full name
Staff/Student/Visitor/Contractor (circle relevant category)
School/Department/Course if staff or student Technician G3
Address & poscode if visitor or contractor
Telephone contact number 017-7577489
School/Department/Course G3
Nature of injury The victim sprained his ankle
Treatment given Bandage
Treatment given by Medical Asisstant
Taken to hospital Yes/No
If yes, which hospital and how taken PKU
Off work as a result of accident/incident? Yes/No

yes

If yes-for many days?