Accidents, Incidents or Dangerous Occurrences Report Form
Please complete the following form after any accidents, incidents or injuries that occur whilst you are working for/with the SU. This form includes all relevant details associated with the incident.
Your Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Status
*
LBSU Staff
Student
Job Title
*
Department
*
Your Manager's Name
*
First Name
Last Name
Your Manager's Phone Number
*
Your Manager's Work Email
*
example@example.com
Your Work 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
*
Student ID Number
*
Student Email Address
*
example@student.leedsbeckett.ac.uk
Date of Incident
*
-
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 occur? (includes remote working and off-campus events)
*
i.e. in my home kitchen
What was being undertaken when the incident 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?
*
Yes
No
Describe what machinery was involved in the incident:
*
i.e. a kettle
Describe any/all injuries sustained as result of the incident:
*
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?
*
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
*
Clear
Once submitted, this form will be sent to the relevant SU team to be kept on file.
Submit
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