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.