Report No:
REPORT OF AN INJURY OR DANGEROUS OCCURRENCE ON UNIVERSITY
PREMISES OR DURING UNIVERSITY BUSINESS
ACCIDENT REPORT FORM
Please note:

Completing this form does not constitute an admission of liability, either by the person making the report or any other person

If more than one person was injured as a result of an accident, please complete a separate form for each person

Data Protection Act 1998 Notice: The information you give us, including any personal or sensitive information, will be held in our electronic database for 4 years
and will be used by us to help us investigate the cause of incidents and for statistical analysis. Details of RIDDO Reportable incidents will be forwarded to Health and
Safety Executive. Relevant information will be disclosed outside the University where it is required by law to do so. In the event of a personal injury claim,
information may be disclosed to the University's Insurers. Anonymised data may also be disclosed to relevant trade union officials.
Campus:
College Road
Leek Road
Section 1: About the person who had the accident
Name:
Blackheath Lane
Beaconside
Other
Employee
Student
Contractor
Visitor
Address:
Male
Are you happy for your Union Health & Safety Representative to be informed of this accident?
Yes
Tel No:
Faculty/Service:
Occupation:
Date form completed:
24 hour or more hospitalisation
3-6 days injury incapacitation
7 days or more injury incapacitation
Section 2: Where did it happen and when did it happen?
In what room or place did the accident happen?
Date:
No
Yes
Yes
Yes
Female
UCU
Unison
No
No
No
Time:
Section 3: About the Accident
How did it happen? (give cause):
Nature of Injury:
Action Taken (e.g. was medical treatment/first aid given?)
Yes
No
If yes, give brief details:
Section 4: About you, the person filling in this form (complete only if different from Section 1)
Name:
Address:
Tel No:
Faculty/Service:
Employee
Student
Contractor
Visitor
Male
Female
Occupation:
Name and address of any witness(es)
Section 5: Immediate Action
Have you contacted the Estates Helpdesk (estates.helpdesk@staffs.ac.uk) to enable an immediate response to dangerous
situations, defective premises or grounds, e.g. icy paths, pot holes, etc.? Please indicate:
Yes
No
If no, detail why not:
Signed – Head of Health & Safety:
Return to: Head of Health & Safety, C346 Beacon Building, Stafford Campus, or email safety@staffs.ac.uk