| Description | Counterfoil book for particulars with sections for name of person (whether killed or injured, with age, occupation, residence), date and hour of accident, date of report to colliery company, by whom reported to colliery company, place of accident, cause and description of accident, nature of injuries, place to which injured person removed, name and address of colliery club doctor attending case, probable duration of disablement (never completed), name of witness of accident, and remarks, with signature (of person completing form) and date at bottom. |