Accident Book

Untitled Document

Please fill out this form to the best of your knowledge.
The results of the report will be sent to the University Risk and Safety Manager.

About the person who had the accident/near miss
Forename:
Surname:
Role/Occupation:
If student, please specify course of study:

Address (of person experiencing accident/near-miss):

Street Address:
Town/City:
Post Code:

About the person filling in this form - repeat if necessary
Forename:
Surname:
Role/Occupation:

Address (of person filling out form):

Street Address:
Town/City:
Post Code:

Details about the accident/near-miss
Report Type:

Date of incident:
Time of incident:

Location:

Building/Grounds: Blenheim Walk
Vernon Street
Rossington Street
Office Building
Other (Please specify)

Room/Approximate location:

Person responsible for area (If known):

Incident details:

Say how the accident/near-miss happened: Please specify in as much details as possible: Give the cause of the accident/near-miss, if you can: Please give details of the cause if known: Has the person who had the accident suffered injury: Please give details of the injury:
Was a hospital visit required:

Name of First Aider attending:

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