LBSU Accidents, Incidents and Near Misses Report Form

Accidents, Incidents and Near Misses Report Form

Please complete the following form after any accidents, incidents, injuries or near misses that occur whilst you are working for/with the SU. This form includes all relevant details associated with the incident.
Are you a First Aider filling this out on someone's behalf?
First Aider's name

First NameLast Name
First Aider's email
example@example.com
Name of person who experienced accident/incident

First NameLast Name
Date of Birth

MonthDayYear
Date
Status

Other
Status
Job Title
Department
Manager's Name

First NameLast Name
Manager's Phone Number
Manager's Work Email
example@example.com
Your Email
example@example.com
Normal hours worked on day of incident
i.e. 09:00 - 17:00
Actual hours worked on day of incident
i.e. 09:00 - 17:00
Society / Student Group Name (if applicable)
Student ID Number (if applicable)
Student Email Address (if applicable)
example@student.leedsbeckett.ac.uk
Date of Incident, accident or near miss

MonthDayYear
Date
Time of Incident

:HourMinutesAM/PM Option
Where did the incident, accident or near miss occur? (includes remote working and off-campus events)
i.e. in my home kitchen
What was being undertaken when the incident , accident or near miss occurred?
i.e. hanging a banner
Describe in detail what happened:
i.e. sequence of events, include weather if outside, footwear/clothing; any relevant details
Was any machinery involved in the incident, accident or near miss?
Describe what machinery was involved in the incident, accident or near miss:
i.e. a kettle
Describe any/all injuries sustained as result of the incident accident or near miss:
i.e. a 5cm shallow cut on the top of my left hand
Who treated the injuries or condition, and what treatment was given?
i.e. Jennah gave me a plaster from a first aid kit
Were there any witnesses to this incident, accident or near miss?
Name of Witness

First NameLast Name
Witness Description
i.e. SU staff, member of the public, contractor, etc.
Witness Email
example@example.com
Witness Phone Number
What action, if any, has been taken to prevent this from happening again?
i.e. reported to CARES or Estates Services
Your Phone Number
Signature
Once submitted, this form will be sent to the relevant SU team to be kept on file and appropriate action taken.
Should be Empty: