6 of
8
PART A
Details of Injured Person, please
detail as much as possible
insuring it is accurate at the
time of the accident/ near
miss
Send reports to:
-
White
Copy: Health and Safety Team
-
Yellow
Copy: HR/Registry
(Staff Incidents to HR, Student Incidents to Registry)
-Pink
Copy: Keep on file within department.
School or professional support
area, and the department
PART B
Date:
DD/MM/YY
Time:
If not exact estimate to the
nearest half hour.
Where:
Detail
building, floor, and department. If
possible note where this close
to/near.
PART C
Describe what happened in as
much detail as possible, and if
required use
a separate sheet.
- The lead up the event.
- How the event occurred
- What activity was being
carried out?
- If there was any machinery
or dangerous equipment/
substances involved.
- If a student was involved,
note what studio space/class
this was being carried out in.
PART D
Specify exactly where on the body
the injury was sustained for
example:
- Left thumb
- Left leg above the knee
- Right arm below the elbow etc
.
Completed by Health
and Safety Team
PART G
-
What happened after the accident
occurred?
- What has been put in place to
prevent this happening again?
- Were there any repairs carried out?
- Had the affected person been
spoken to?
PART F
Note the name of the Head of
department/ Responsible person/First
Aider or Technician at the workplace
where it occurred
PART E
- Tick box if first aid was
administered.
- Detail full name of trained
first aider.
- Give full details of anyone
who was present when the
event occurred.
- Note who is filling the form
out and their full name.
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