FM ENV REC 040
V. 5.0
Report of Environmental Incident/Near-Miss/Nonconformity
Reporting Responsibilities
Level 1, 2 or 3 incidents to be reported immediately to Security on Ext: 333
All environmental incidents to be reported to SHE Section by completing PART 1 below
Level
Category
Example description of incident
Local incident
A leakage or spillage of an environmentally hazardous
substance that is contained within the local area, has not
caused contamination and requires a relatively minor
clean up by staff involved (FMENVREC049 Spill
Containment- Locations and Competent Persons)
Local but significant incident
A leakage or spillage of an environmentally hazardous
substance that is contained on site but may require
significant clean up by other UCLan staff or a contractor.
4
3
contained on site
Minor Incident - Breach of exemption
2
where the breach does not require United
Utilities or Environment Agency to be notified.
Major Incident - Breach of exemption or
1
legislation (notifiable to Environment Agency
or United Utilities)
An exemption limit has been breached. A list of
exemptions that the University has for our operations
(water and waste) can be found on the staff intranet
Leakage or spillage of oil, other hazardous substances
or waste that escapes from the site (e.g. into a brook,
canal, river, air or uncovered ground).
PART 1
Section to be completed by the witness or Security/SHE on behalf of the
witness. Completed forms should be sent to the SHE Section in VE 202 or sent by
email to shesection@uclan.ac.uk
Details of witness
UCLan Student ☐
Member of staff ☐
Visitor ☐
Contractor ☐
First Name: Click here to enter text. Surname: Click here to enter text.
Job Title (if staff):Click here to enter text.
Location at UCLan:Click here to enter text.
School/Company/Service/Section: Click here to enter text.
Tel No: Click here to enter text.Email Address: Click here to enter text.
Incident Details
When did the incident occur? (date) Click here to enter text. (time): Click here to enter
text.
Where did the incident occur?: Click here to enter text.
FM ENV REC 040
Please provide a short description of incident including (further space on next page):
1. Estimated quantities: Click here to enter text.
2. Details of cause (if known): Click here to enter text.
3. Mitigation measures already taken (if any): Click here to enter text.
4. How the incident happened: Click here to enter text.
Did anyone else witness the incident? If so, provide names: Click here to enter text.
Signed: Click here to enter text.(Unless submitted by email) Date: Click here to enter text.
PART 2
Section to be completed by SHE staff ONLY
Type & Level of Incident
Incident: ☐
Level 1: ☐
Near-Miss: ☐
Level 2: ☐
Level 3: ☐
Non-Conformity: ☐
Level 4: ☐
Root Cause & Incident Handling
What was the root cause of the incident?: Click here to enter text.
What went well and not so well during the handling of it? Click here to enter text.
Reporting
All incidents should be reported to the line manager or the manager of the area of activity
where the incident occurred to discuss actions arising.
Name: Click here to enter text.Email Address: Click here to enter text. Tel No: Click here
to enter text.
Date reported: Click here to enter text.
Action
Explain what action has been agreed to prevent the accident/incident/near miss from
happening again and attach any e-mail correspondence: Click here to enter text.
Signed: Click here to enter text.
Environmental Incident Number:
Date: Click here to enter text.