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?
*
Yes, I'm a First Aider filling this out on behalf of someone else
No, I'm the one who experienced the accident and am filling this out for myself.
First Aider's name
First Name
Last Name
First Aider's email
example@example.com
Name of person who experienced accident/incident
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Status
*
LBSU Staff
Student
Job Title
Department
Manager's Name
First Name
Last 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
*
-
Month
-
Day
Year
Date
Time of Incident
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/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?
*
Yes
No
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?
*
Yes
No
Name of Witness
*
First Name
Last 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.
Submit
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