Glass Incident Register

All fields marked (*) are required

Contact Details of Person Submitting this Incident *

Contact Details of Injured Person *

Age of Injured Person*

Date and Time of Incident *

Address where incident occurred *

Building Classification *

Glazing type causing incident *

Nature of Injury *

Cause of Injury *

Can we contact you regarding this incident? *

Yes -
No -

Can we use this info for training or presentation? *

Yes -
No -

Upload pictures or any other documentation - (if applicable)