University of West London Accident / Incident Form
ACCIDENT / INCIDENT FORM
Date rcvd by Safety Office: _ _/_ _/_ _
Safety Office reference: _ _ _ _ _
In the event of a serious accident or incident, you must notify the University Safety Office immediately by calling 020 8231 2745
(Out of hoursemergency contact: dial 0844 8222888 quoting reference LBE24).
Use this form to report all accidents, health-related incidents, dangerous occurrences and near-misses (a near-miss is an unplanned event which does not cause injury or damage but has the potential to do).
This form should be completed by the person involved or a responsible person (e.g. First Aider, Manager, Lecturer or other member of University of West London staff) attending the incident.
Confirmation of receipt will be sent, so please ensure Sections 1 & 6 are completed in full.
If completing this form by hand, use BLOCK CAPITALS throughout and mark the appropriate boxes
If completeing the form electronically, double-click the appropriate boxes to mark them as checked
Remember to save the form to your desktop or other location so that you can e-mail it once completed!
Do you consent to your personal details being disclosed to Trade Union and other employee Safety Representatives? Yes No
If you need help filling in this form, contact the Safety Office on ext. 2745 (020 8231 2745). Thank you.
SECTION 1DETAILS OF PERSON INVOLVED / AFFECTED
First Name (in CAPITALS):Date of Birth:
(dd/mm/yr)
Surname (in CAPITALS):FemaleMale
Address(incl. postcode):
Occupation/Job title:Contact Number:
E-mail address:
StudentSchool/Dept:Course:
Student number:
StaffSchool/Dept:Staff ID:
VisitorVisiting who/what/where:
ContractorContracted by (UWL Manager/dept):
SECTION 2LOCATION OF INCIDENT
Site St Mary’s RoadParagon Teaching Block
Walpole HouseParagon Halls of Residence
ReadingPlacement*
Work Based Learning*
Other*
*If it was not a University site, please give the address and postcode where this happened:
Where exactlydid the incident/accident occur (specify building/room number/area)
SECTION 3DETAILS OF INCIDENT
Date of incident (dd/mm/yr):Time of incident:
Person in charge at the time of the incident:
Incident reported to:
Date reported(dd/mm/yr):Time reported:
Description of incident (include circumstances leading up to the incident, what you were doing, and any factors that may have contributed to the incident, eg. weather conditions, lighting, surface conditions):
Continue on a separate sheet if necessary
SECTION 3 (continued)TYPE OF INCIDENT
Assault /violence Hit by moving/flying/falling object
Contact with electricity or an electrical discharge Hit by moving vehicle
Contact with something hot Injured whilst handling, lifting or carrying
Contact with something sharp Slip / trip between levels *
Exposure to or contact with hazardous Slip / trip on the same level
substances including hot liquids Work related stress
Fall from a height * Work related upper limb disorder
Hit by (contact with) fixed/stationary objectNone of the above / health-related incident
Hit by moving machinery or material being machined
*State the distance fallen / between levels:
SECTION 4DETAILS OF INJURY OR CONDITION
If no injury or illness occurred, mark this boxand proceed to Section 5
Part of the body affected (please be specific, e.g. right knee, left arm, right index finger):
Nature of injury (e.g. cut, bruise, sprain, burn):
First Aiderattended?No Yes Name of First Aider:
Sent to Hospital?No Yes By ambulance taxi car other
Details of treatment on site, materials used and any other comments (e.g. advised to visit GP)
SECTION 5WITNESSES TO ACCIDENT / INCIDENT/ NEAR-MISS
Were there witnesses? No Yes Please give contact details (name, address, phone, e-mail)
SECTION 6 PERSON COMPLETING THIS REPORT
First Name: Surname:
Address(including postcode):
Occupation/Job Title: Signature:
Date form completed: (e-mailed forms do not need to be signed provided you can be identified by your e-mail details)
Please send this form to the Safety OfficeWH301C, Walpole House, Ealing W5 5AA or e-mail it to
Confirmation of receipt will be sent, so please ensure Sections 1 & 6 are completed in full.
To be completed by Safety Office
Management Action form sent to Date MAF sent
RIDDOR No Yes Date reported How was it reported?
Name & signature of person submitting RIDDOR
If you need help filling in this form, please contact the Safety Office on 020 8231 2745 Page 1 of 3
Accident_Form_UWL_120106