Accident Reporting – Kehillas Federation

"*" indicates required fields

1. Please fill in the details below of the person who had the accident.

If there was more than one person involved, please add their details below.

Name*

First name Surname

Address*

Street Address City Post code Country

Phone*

Age*

Email*

Details of additional persons invloved

Name

Address

Age

Email

Phone

Please add a new row for each additional person involved.

2. About you, the person filling in this record if you were not the person who had the accident.

Name*

First name Surname

Address*

Street Address City Post code Country

Phone*

Email*

3. About the accident.

Date of the accident*

Time of the accident*

:

Where the accident happened*

Street Address City ZIP / Postal Code Country

Please state which room/area*

How the accident happened. Give the cause if you can.*

If the person(s) who had the accidents suffered an injury, what was the injury?*

What action was taken? Was an ambulance/Hatzola called?*

4. Please sign and date the record.

Signature*

Date*

5. For the person signing the record

Signature*

Date*

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