Accident_ incident_ dangerous occurrence report form by liuhongmeiyes

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									  REPORT OF AN INCIDENT, ACCIDENT, DANGEROUS
  OCCURRENCE OR NEAR MISS.
  This form must be completed and returned within 3 working days of the
  incident to the Safety Officer for Health & Safety Incidents.

  If in doubt report the incident immediately to the Safety Officer by telephone x 5744 or x 5745.

  This document and any copies are confidential and must be filed securely.

INCIDENT INFORMATION                                                                              Office Use Only
Date:                                                  Time: (use 24 hr clock)                    Date received:

Location,                                                                                         File No.:

including Campus and Room Number                                                                  Ref No:

Please classify the accident or incident by ticking the boxes:                                    Site:

     Health & Safety (please also complete parts A & C below)                                        In        Out

                                                                                                  Agent:
                  Accident         Incident     Near Miss

     Environmental (please complete Parts A, B and C below as appropriate)                        Hazard:

Please state briefly what happened, e.g. slip, trip, chemical spill etc.




Names & addresses of witnesses:                           PRINT name of First Aider:

1)                           2)



PART A - PERSONAL INFORMATION (INJURED PARTY)

Surname:                                Forename(s):                  Male          Date of       Sex:
                                                                      Female        Birth:           M         F

Address:                                                  Student        Employee/Student         Age:
                                                          Employee       No.
                                                          Visitor
Postcode:                                                                                         Fac/Dir:

                                                       Occupation/ Course:                           Employee
                                                                                                     Visitor
Phone No.:                                                                                           UG/PG

Faculty/Directorate:                                   Supervisor:


Details of Injury: (Please state nature of injury and part of the body affected, state L or R):   Nature of injury:




First aid given?             Yes        No    Please state first aid treatment given:             Treatment:




Person sent to:              Hospital                   Home                     Sports injury?
                             Returned to work           Other (give details)         Yes
                                                                                     No


Document Status
Page 1 of 2                                                                                                           Aug 2012
PART B – ENVIRONMENTAL IMPACT INFORMATION                                                       Office Use Only
Provide details of any materials/liquids spilt or discharged, and the amount                      Regulator Report?
(kg/litres) (estimate if necessary); State whether discharge affected air,                        Internal Report?
watercourses, drains and/or permeable ground, and type of damage:
                                                                                                Impacts :

                                                                                                  Air    Drain       River
                                                                                                  Ground/ groundwater
                                                                                                  Permeable Land

State what immediate action was taken to mitigate environmental damage:                         Material nature :
                                                                                                  Toxic/Hazardous
                                                                                                  Non-toxic      ODS or GHG

Clean up required / implemented?



Longer term mitigation / remediation required / implemented?




PART C – ACCIDENT OR INCIDENT FOLLOW UP AND INVESTIGATION REPORT
To be completed by Supervisor / Line Manager / Member of Staff In-Charge

Name of Investigator:                         Job Role:          Faculty / Directorate:         Phone Ext. No.:



Date person ceased work / studies:                               Date person returned to work / studies:

Brief statement from injured or affected person:




Signature of injured or affected person:                                                        Date:


Actual or possible causal factors (identify and state potential root cause):



Involvement of equipment/ substances/ other persons:



Property damage:



Preventive (for near misses) and/or corrective/remedial action required to avoid re-occurrence :



Signature of Investigator:                                    Date:



                           Continuation Sheet : Yes/No                 If yes, Page __ of __ Pages
      Please complete separate investigation forms for environmental & personnel damage associated with individual incident.



Document Status
Page 2 of 2                                                                                                                  Aug 2012

								
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