Notice of Accident or Dangerous Occurrence

Notice
(Vide rule 96)

This space is to be completed
by the Inspector of Factories.

District ………………………
Date of Receipt .……………
Accident No. ………………
Industry………..…………….
Causation No. ………………
Sex (MW B or C)…………..

Other particulars injury, etc.						
e.g. fatal, leg injury, arm

Date of investigation……………………………………………………………………………
Result of investigation …………………………………………………………………………

1. Name of Factory

2. Address of works where accident or
dangerous occurrence happened
      
3. Nature of Industry.

4. Branch or Department and exact place where the 
accident or dangerous occurrence happened.

5. Injured person’s name and address.

6. (a) Sex
(b)Age (Last birthday)
(c) Occupation of the injured person

7. Date and hour of accident or
dangerous occurrence

8. Hour at which he started work on day of accident.

9. (a) Cause or nature of accident or dangerous occurrence.
(b) If caused by machinery:

(i) Given name of machine and part causing the accident (b) (i).

(ii) State whether it was moved by mechanical power at that time (b)(ii).

(c) State exactly what injured person was doing at that time (8).

10. Nature and extent of injuries (e.g. fatal, loss of finger, fracture of leg, scald, scratch followed by sepsis)………

11. If accident is not fatal, state whether injured person was disabled for 48 hours or more.

12. Name of Medical Officer in attendance on injured person.

I certify that to the best of my knowledge and belief the above particulars are correct in every respect.

(Signature of Occupier or Manager)
Date of dispatch of report ……………………….

*