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Accident and incident report form

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Accident and incident report form

Accident / Incident Report Form.

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Accident / Incident Report Form.
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School / Department/Service Completing the Report:*
Accident / Incident Date:*
DD slash MM slash YYYY
Accident / Incident Time:*

Hours :

Minutes
Accident / Incident Location:*
Please specify:*
Specific Room No or Location:*

Report Type:
Type:*
Select all of the items that apply.
- Injury (No Lost Time)
- Injury (Lost Time)
- Fatality
- Road Traffic Accident
- Verbal Abuse / Aggression
- Ill Health / Self Harm
- Environmental Damage
- Theft / Vandalism
- Near Miss
Absence Date:*
DD slash MM slash YYYY
Return to Work Date:*
DD slash MM slash YYYY
Description of the Accident / Incident:*

Apparent Cause:*
Select all of the items that apply.
- Contact with Electricity
- Contact with Hand Tools
- Contact with Harmful Substances
- Contact with Moving Machinery
- Contact with Moving/Falling/Flying Object
- Exposed to the Cold
- Medical
- Exposed to Fire
- Exposed to Smoke
- Fall from Height
- Hit Fixed Object
- Injured Lifting/Handling/Carrying
- Physical Abuse
- Verbal Abuse
- Theft
- Slip/Trip/Fall
- Trapped by something Collapsing
- Other

Details of the Person Involved:
Person Involved:*
- UN Employee
- 1DF Employee
- Student
- Contractor
- Member of the Public / Visitor
Name
Forename: Surname:
Job Title:
School / Department / Service:
Course (If Applicable):
Employee / Student ID:
Address:
Postcode:
Telephone:
Mobile:
Email:
Enter Email Confirm Email
Gender:
- Male
- Female

Details of Injury

This section MUST be completed. Where there is more than one injury place a number on the part of the body affected and put the same number in the type of injury.
Body Part Affected:
Please give as accurate description as possible.
Resulting Injury:*
- Abrasion / Bruise
- Amputation
- Burn / Scald
- Concussion / Internal Injuries
- Crushing
- Dislocation
- Electric Shock
- Epileptic Seizure
- Eye Injury
- Fracture
- Lacerations / Open Wound
- Penetrating Injury
- Respiratory
- Sensitisation / Irritation
- Shock / Stress
- Sprain / Strain
- Other

Treatment
Treatment Given:
- None
- First Aid Treatment
- Sent / Taken to Hospital
- Sent / Taken Home
First aid consumables used:
First Aider:
Hospitalised for more than 24 hours:*
- Yes
- No
- Unknown

Witnesses
Were there any witnesses to the accident/incident:*
- Yes
- No
Details of First Witness:
Witnesses is:
- UN Employee
- 1DF Employee
- Visitor
- Contractor
- Member of the Public
- Student
Name
Forename: Surname:
Job Title:
School / Department / Service:
Telephone:
Mobile:
Employee / Student ID:
Email:
Enter Email Confirm Email
Date
MM slash DD slash YYYY
Confirms Details are Accurate:
- Yes
- No
Was there another witness:
- Yes
- No
Details of Second Witness:
Witnesses is:
- UN Employee
- 1DF Employee
- Visitor
- Contractor
- Member of the Public
- Student
Name
Forename: Surname:
Job Title:
School / Department / Service:
Telephone:
Mobile:
Employee / Student ID:
Email:
Enter Email Confirm Email
Date
MM slash DD slash YYYY
Confirms Details are Accurate:
- Yes
- No
Was there another witness:
- Yes
- No
Details of Third Witness:
Witnesses is:
- UN Employee
- 1DF Employee
- Visitor
- Contractor
- Member of the Public
- Student
Name
Forename: Surname:
Job Title:
School / Department / Service:
Telephone:
Mobile:
Employee / Student ID:
Email:
Enter Email Confirm Email
Date
MM slash DD slash YYYY
Confirms Details are Accurate:
- Yes
- No

Details of the Person Making the Report
Person Type:*
- UN Employee
- 1DF Employee
- Visitor
- Contractor
- Member of the Public
- Student
Name*
Forename: Surname:
Telephone:*
Mobile:*
Employee / Student ID:*
Email:*
Enter Email Confirm Email

Consent
Trade Union Safety:*
Trade Union Safety Representatives appointed by a trade union recognised by the university are also entitled to investigate accidents where they deem necessary. Do you consent to the release of information within this report where requested?
- Yes
- No
Declaration & Consent:*
This form will be held by the university for the period detailed in our Record Retention Schedule. The information within it may be used during accident/incident investigation or to prevent reoccurrence. It may also be disclosed to legal or other third party professionals should the need arise.

I confirm that the above information is correct to the best of my knowledge and consent to the release of this information for the purposes mentioned above.
- Yes
- No

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