Accident Report Form

At Middle World Farms, safety is our priority. Please use this form to record any accident, injury, or near-miss that occurs on the farm. Include as much detail as possible — the more information you provide, the better we can respond and prevent recurrence. All submissions are treated confidentially and reviewed by our Designated Safeguarding Lead.

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Incident Details

Date / Time *

Date

Time

Location on Farm *Field Block 1Field Block 2Field Block 3Field Block 4Field Block 5PropagationWashing packingOfficeStaff AreaCompostingWorkshop

Description of Incident *

Next

Injured Person's Details

Full Name *

Full name of person hurt

Number the

Age *

Contact Number

Phone number

Role *StaffVisitorVolunteerStudent

What was or is your role at Middle World Farms

Next

Injury Details

Nature of Injury *CutsBruisesFractureBurnsCrushOther

Body Part Affected *

Was First Aid Given? *

• Yes
• No

Was Emergency Help Called? *

• Yes
• No

Hospital Treatment Required? *

• Yes
• No

First Aider’s Name *

Next

Witness Information

If applicable

Witness Name

Witness Contact (Phone)

Witness Statement

Witness Signature

Clear Signature

Next

Person Completing the Report

Your Name

Your RoleStaffVolunteerThird ChoiceManagerVisitor

Date *

Any supporting photos or files to upload?

Drag & Drop Files, Choose Files to Upload

Signature

Clear Signature

Submit