e-form Accident Notification Form Form should reach OHSA (email: ohsa@ohsa.mt) within seven (7) days after the accident in terms of LN 52/1986 Article 22.2(b) Employer's Name ID Card No. Company Name Company Registration No.
(MFSA Reg. No.) Postal Address Type of Industry Email Telephone Date of Accident No. of Persons involved Place /
Address of Accident Days out of Work (working days) Person filing the Accident Notification Name and Surname Position within the Company Signature

Details of Injured Person(s) Name and Surname ID Card No. Gender M F X Address Age Job Title Name and Surname ID Card No. Gender M F X Address Age Job Title Name and Surname ID Card No. Gender M F X Address Age Job Title Name and Surname ID Card No. Gender M F X Address Age Job Title

Type of Accident Hit by a moving, flying or falling object Use of Hand Tools Fall on Same Level Injured while handling, lifting or carrying Fall on Lower Level Injured while using means of transport Inhaling of fumes/gases Physically injured after being assaulted by human or animal Burn Use of chemicals Electrocuted Striking against object Other (specify) Type of Injury Fracture Laceration with wound Sprain Burn Strain Chemical Burn Contusion Amputation Other (specify) Part of Body injured Hand(s) Back Leg(s) Face Head Eye(s) Forearm(s) Foot (Feet) Other (specify)