Incident Report Form
Uni Ref:
Completed forms must be sent to Health and Safety Services within four days of the incident. If this is not possible, contact Health and Safety
Services by phone (ext. 5165)
PART 1 – INCIDENT NOTIFICATION
TYPE OF INCIDENT ** (See end of form for additional information)
INJURY
VIOLENCE / AGGRESSION
NEAR MISS
WORK RELATED ILL HEALTH
PROPERTY DAMAGE
A. INJURED / ILL PERSON DETAILS (shaded areas not required for staff incidents)
Staff
UG Student
PG Student
Visitor
Contractor
Title:
Age:
Surname:
Forename(s):
Home address (including Postcode):
Job Title:
Other
(state):
Male
Female
Faculty/Dept:
Home Tel No:
Email:
I authorize you to send a copy of this form to my Union:
UCU
UNITE
UNISON
(Please Select)
Signature of injured person:
B. INCIDENT DETAILS
Date of Incident:
Time of Incident:
Building:
Room Number:
(am/pm)
Exact Location (If the incident occurred outside, please give enough detail to be able to find the location):
DESCRIPTION OF INCIDENT (Give full details of what happened and what people were doing at the time)
IRF – Jan 2015
Health & Safety Services
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C. INJURY DETAILS
Indicate the TYPE of injury & LOCATION
e.g. bruised left foot, fractured left arm, cut right hand, etc.
Did the injured person:
Become Unconscious
?
Require Resuscitation
TREATMENT
Immediate
None
Self
First Aider
(Name):
?
ABSENCE
Afterwards
GP
Hospital (from scene)
Hospital (at a later date)
Admitted for over 24 hrs
Returned same day as incident
Will be, or is likely to be, absent for 7 or more days
Will be, or is likely to be absent for less than 7 days
Other (please specify):
D. WITNESSES (give names and contact details, phone number / email ideal)
E. DETAILS OF PERSON COMPLETING SECTIONS A-E
Print Name:
Faculty / Dept:
Date:
Signature:
Position held:
Tel No:
Head of Department informed?
Yes
No
Departmental Safety Officer informed?
Yes
No
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PART 2 – INCIDENT INVESTIGATION
F. INVESTIGATION
SECTION F IS TO BE COMPLETED BY AN APPROPRIATE PERSON
THIS WILL USUALLY BE A MANAGER / ACADEMIC TUTOR OR DEPARTMENTAL SAFETY OFFICER.
IF A FULL INVESTIGATION IS NOT REQUIRED, PLEASE TICK WHY:
The incident was not connected to University activities OR Defective University equipment / premises.
The incident was insignificant, has not happened before, and is extremely unlikely to happen again.
Other (give details):
Name:
Signature:
Describe how the incident may have been / was caused.
Immediate Causes (What directly caused the incident?):
Root Causes (What circumstances led to the situation arising?):
Describe any precautions which were already in place.
Following the investigation, are any changes required to existing Risk Assessments related to the incident?
Yes
No
Risk Assessment not required
Please attach the related risk assessments in place *at the time* of the incident, and copies of any revised/newly
created risk assessments if available.
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Describe any actions taken or planned to reduce or prevent the risk of this incident recurring.
If remedial work has been requested through Estates, please note the Job Request Number here:________________
Actions to address the Immediate Causes:
Actions to address the Root Causes:
Head of Department informed?
Yes
No
Investigator Name:
Departmental Safety Officer informed? Yes
Signature:
Faculty / Dept:
Date:
Position held:
No
Data Protection – Information on this form is held in accordance with data protection legislation and used for the purposes of investigation and
securing the health, safety and welfare of people at work.
** Incident Types
INJURY (An incident has occurred which caused an injury)
NEAR MISS (An incident has occurred OR a dangerous situation exists which could cause an injury, but by chance has not)
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