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This form must be filled in by an employer or other responsible person.

If more than one person was injured as a result of an accident, please complete a separate form for each person.

This form can be used to notify an Injury or Dangerous Occurrence covered by the:

  • Health and Safety at Work etc Act 1974 (as applied to the Island)
  • Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1985 (as applied to the Island).

Unless specified, all fields must be completed.

Subject of report *
Subject of report
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