ACCIDENT / INCIDENT REPORT FORM (GUILD)
This form may be completed by any member of Guild / University Staff or a student (but preferably a First Aider). Please complete every part of the form; all details pertaining to employees are required by law. Please return the completed form to the Mr Orlando Murrish, Guild Health & Safety Co-ordinator, 1st Floor Devonsire House, Streatham Campus, as soon as possible. Telephone 01392-263541. Retain a copy for your own records (the Guild Health & Safety Co-ordinator will forward copies to the University Safety Department where applicable). This form needs to be completed for accidents or incidents which occur off campus and include student activities.
1:About the person who had the accident
Sex: M / F
Name (Prof/Dr/Mr/Mrs/Miss/Ms) :-…………………………….…….…………..Date of birth:-.… / ….. / ….. Address (Home / Term time):-......................................................................................................................... ………………………………………………………………………………...Postcode:-………………….… Telephone:-………………………E-mail:-……………………………Occupation:-...................................
Category:- (tick appropriate boxes) ▼ □ Staff
□ Academic & Related □ Clerical & Secretarial □ Technical □ Cleaning / Domestic □ Catering □ Security □ Maintenance □ Estate □ Guild □ Portering
School / Division / Unit:-…………………………………………………………. □ Student □ Contractor
□ Undergraduate □ Postgraduate □ Postdoctoral Name of contactors employer:…………………………………………………. ……………………………………….…………
□ Visitor / Member of the public
□ Accompanied □ Unaccompanied
□ Other (please state) ………………………..
2:About you, the person filling in this record
▼If
you did not have the accident write your address and occupation.
Name:-……………………………..…….…Status (e.g. First Aider, Supervisor, Witness)……………………….. Address (Home / Term time):- ......................................................................................................................... ………………………………………………………………………………...Postcode:-…………………… Telephone:-………………………E-mail:-……………………………Occupation:-...................................
3:About the accident
Say when it happened:-.…. / ….. / ….. Time………………. am /pm Say where it happened. State which room or place:-………………………………………………………. …………………………………………………………………………………………………………………. School / Dept / Div :-………………………..Building:-…………………………Room:-…………………. Say how the accident happened. Give the cause if you can……………………………………………….. ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………please turn over
3:About the accident (continued)
What happened?:- (tick appropriate boxes) □ Actual personal injury □ Potential personal injury □ Hit by object □ Slip / Trip / Fall level surface □ Fall from height (…….meters) □ Hit by vehicle □ Exposed to harmful substance □ Contact with Electricity □ Exposed to explosion □ Physically assaulted by person □ Injured while handling, lifting or carrying □ Injured while using machinery □ Contact with heat / cold □ Injured by animal
If the person who had the accident suffered an injury, say what it was:-………………………………… …………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………….
Nature of the injury?:- (tick appropriate boxes) □ Fatality □ Amputation □ Bruise □ Burn heat / cold □ Burn corrosive □ Compression □ Concussion □ Cut □ Dislocation □ Puncture □ Sprain □ Strain □ Unconsciousness Part of the body affected?:- (tick appropriate boxes) □ Head □ Eyes □ Nose □ Mouth □ Neck □ Shoulder(s) □ Upper Arm(s) □ Forearm(s) □ Hand(s) □ Finger(s) □ Chest □ Abdomen □ Upper Back □ Lower Back □ Hips □ Upper leg(s) □ Lower Leg(s) □Foot (feet) □ Toe(s)
Emergency Action; name of the person in attendance:-……………………………………………
First Aider:- □ Yes □ No Telephone…………………………E-mail…………………………………..
Witness(es):Name:-……………………………………Telephone…………………….E-mail……………………….. Name:-……………………………………Telephone…………………….E-mail………………………..
Outcome, injured person:None of these (please describe):-
Received first aid?:Returned to work?:Was taken home?:Was seen by doctor?:Was taken to hospital?:-
□ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No
…………………………………………………………. …………………………………………………………. …………………………………………………………. …………………………………………………………. ………………………………………………………….
Person making the report
Please sign the record and date it:-………………………………………………….Date:-….. / ….. / …… ! end of the report- return it to Mr Orlando Murrish, Guild Health & Safety Co-ordinator, Room 7,
Cornwall House, Streatham Campus. Telephone 01392-262432.
4: For the employer only (Guild Health & Safety Co-ordinator or University Safety
Department). □ Date form received:-……………………………. Reportable under RIDDOR? □ Yes □ No
□ Date form acted upon:-……………………………………………………………………………………..
▼ Complete this box if the accident is reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR).
How was it reported?:-...................................................................................................................................... Date Reported:-.…./ ….. / ….. Signature:- ………………………………………………………………….
File: guild accident form.doc