For The Health & Safety Advisor Use Log
number:
Signature:
..................................
If applicable, HSE report number:
Date:
.........................................
ACCIDENT, INCIDENT, NEAR MISS REPORT FORM
This form must be completed as soon as possible after the accident, incident or near miss and
forwarded to the University Health & Safety Office without undue delay in all cases to
health.safety@canterbury.ac.uk
Name of Person Depar
Making the Report: t
-
ment:
Accident Incident Near Miss
Type of Date: Time
Occurrence: :
At which campus did
the Accident, Incident Canterbury Broadstairs Folkestone Medway Salomons
or Near Miss Occur?
Location of Building, Room Number etc
Occurrence:
Brief Details of (include police incident/crime number if applicable)
Occurrence
Please continue over the page if
required
Person Involved Full Name: Contact Tel No:
In the Occurrence
Details of
Personal Injury (If
an accident) Please continue over the page if
required
Category of Employee Student Contractor Visitor
Injured Person
Injured Person’s
Job Title:(Employee Department:
only)
Home Address &
Postcode of Age Gender
Injured Person
Please Email to: health.safety@canterbury.ac.uk Revised August 11
For The Health & Safety Advisor Use Log
number:
Signature:
..................................
If applicable, HSE report number:
Date:
Details of Witness Name and Address:
.........................................
to the above: if
any
Was First Aid Details of
Administered? treatment
given:
Who administered
First Aider:
first aid/treatment?
Was an Was the Injured
Ambulance Person Taken To
Called: Hospital?
Other Comments:
Please continue over the page if required
All information will be treated as confidential and in accordance with the requirements of the Data Protection Act
1998.
To add another page, please place cursor below this line and press Enter.
Please Email to: health.safety@canterbury.ac.uk Revised August 11