FORM 15: Accident Book
[Regulation 66]
Serial No _______________
Date of notice ______________
Time of notice __________________
Name and address of the injured person __________
Sex ____________
Age ____________
Insurance No _______________________
Shift, department and occupation of employee ________________
Injury _______________________
Date _________________________
Time ___________________________
Place ___________________________
Cause of injury ___________________
Nature of injury ___________________
What exactly was the injured person doing at the time of injury ______
Name, occupation, address and signature or the thumb impression of the persons giving notice ___________________
Signature and designation of the person who makes the entry _______
Name, address and occupation of two witnesses
_______________________________________________________________________________________________
Remarks, if any ___________________
