QUESTION 4 CONTINUED

　　NEILSON CARPET FACTORY

　　ACCIDENT REPORT FORM

　　THIS FORM MUST VE COMPLETED IN CAPITALS BY THE PERSON REPORTING THE 　ACCIDENT ON THE DAY OF THE ACCIDENT

　　FULL NAME OF INJURED PERSON __________________________

　　TITLE (MR/MRS/MISS/MS) _______________________________

　　HOME ADDRESS _________________________________________

　　_________________________________________

　　__________________________________________

　　STATUS OF INJURED PERSON __________________________________________

　　DATE OF ACCIDENT __________________________________________

　　TIME OF ACCIDENT __________________________________________

　　LOCATION OF ACCIENT __________________________________________

　　DETAILS OF INJURY __________________________________________

　　CAUSE OF ACCIDENT _________________________________________ (HOW DID IT HAPPEN?)

　　__________________________________________

　　__________________________________________

　　TAKEN TO HOSPITAL YES [] BY AMBULANCE [] BY CAR []

　　(Please tick) NO []

　　DO YOU CONSIDER THE COMPANY IS AT FAULT? YES/NO(delete which does not apply)

　　IF 'YES’ GIVE REASON _________________________________________

　　__________________________________________

　　ACCIDENT REPORTED BY __________________________________________

　　COMPANY STATUS __________________________________________

　　DATE SIGNATURE