Accident / Incident Report

Accident and Near-Miss Report Form
This form must be completed immediately after the incident by the responsible person or the injured person if they are able to do so. First aiders and Security should complete the form if they attend.

Near misses and dangerous occurrences can be reported by whoever witnesses the incident or when they first become aware.

If an accident or near-miss takes place at your activity or event and you do not report it, your group may be subject to disciplinary action.
Type of Incident*
Is this a club or society related incident?*
Club / Society Name*
Date of incident*

DayMonthYear
Time of incident*

Hour Minutes

AM/PM Option

Location of incident

Please provide as much information as possible.
Did the incident take place on campus?*

YesNo
Where on campus did the incident take place?*
Which campus did the incident take place on?*

ChelmsfordCambridgePeterboroughLondon Farringdon CampusLondon East India CampusWrittle
In which room/area did this incident take place in?*
Please specify the room number, building and exact location.
Where off-campus did the incident take place? Please be as exact as possible.*

Street Address

Street Address Line 2

CityCounty

Post Code

About the Incident

Please provide us with exact details about the incident
Description of incident (please provide as much information as possible)*
Was anyone injured?*

YesNo
Please provide details on any first aid or treatment provided to the injured party*
What happened after the incident?*
If taken to the hospital, please provide further information on any treatments*
If other, please provide more information*

About the person involved in the Incident

You can report the incident for yourself or on someone else's behalf.
Who was involved in the incident?*
Name*

First NameLast Name
Email*
example@example.com
SID / Staff Code (if ARU Student or Staff member)
Contact number*
Was the person involved under the age of 18?*
Which campus do they consider their "home" campus?*

ChelmsfordCambridgeLondon Farringdon CampusLondon East India CampusPeterboroughWrittle

Witnesses of the Incident

Witnesses can help us get a better understanding of an incident. Enter the details of any witness/s to the incident and we will contact them if required. There's no limit to the number of witnesses you may add though generally 1 or 2 is sufficient.
Was there a witness present?*
Do you have contact details for the witness(es)?
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Witness Occupation (Student/Staff/Public)
If you selected yes, then we may be in touch to request these details.

Before you submit this form
Please ensure the details you have provided are factually correct and accurate. Once the form has been submitted, changes can only be made by contacting ARU Students' Union.

If you require this form in a different format or if you have any queries about this form, please contact r.davies@angliastudent.com.
Please sign to confirm that the details you have provided are correct and accurate to the best of your ability

Powered by Jotform SignClear
Should be Empty:

Accident and Near-Miss Report Form