Appendix F

Fire incident report form

This form MUST be completed in FULL and forwarded within 24 hours of the incident to

a) University Fire Officer; b) Campus Living Health and Safety Co-ordinator (contact details below)

Section A - Incident details

Date: / LU Gatehouse contacted / Yes No
Time: (24 hour please) / Fire signal received in security Gatehouse / Yes No
Building Name, Block Number + Room Number / Fire Brigade requested / Yes No
Confirm address displayed on Fire Panel / Security personnel in attendance? / Yes No
Evacuation / Yes No / Duty Electrician called to fire alarm fault/repair / Yes No
SMS text received within 24 hrs of incident (if applicable) / Yes No / Area checked/panel reset / Yes No
Incident types
False alarm - malicious / Yes No / Cause of fire alarm
Interference with fire alarm detection equipment / Yes No / Smoke/steam from cooking. / Yes No
Misuse of fire fighting equipment (specify below*) / Yes No / Steam from showers. / Yes No
False alarm - accidental damage / Yes No / Aerosol -deodorant/hairsprayetc / Yes No
False alarm - contractors (welding, grinding etc.) / Yes No / Dust, gases, fumes or other / Yes No
Other fire related incident (fire doors damaged etc) / Yes No / Candle, incense sticks etc. / Yes No
Additional information / Cigarette fumes / E-Cigarette etc. / Yes No
Unattended cooking / Yes No / Fire alarm system fault / Yes No
Fire door(s) held open / Yes No / Lab process/procedure, equipment etc / Yes No
* Fire equipment used(please indicate the number used adjacent to the extinguisher type)
Water / D/Powder / Foam / C02 / F/Blanket
Description of the incident
Hall of residence only
Does the Hall Manager or the Sub Warden consider disciplinary action is required?
(if yes, please ALSOforward the form to the Hall Warden to investigate & complete Section B) / Yes
No
Reported by: (Print Name) / Email Address: / Date sent

Section B- Disciplinary action

Category of offence (see guidance - discipline & fining in Halls)
Details of discipline/fine recommended for this incident by Warden:
Fine / Yes No
Amount £____ / Community service / Yes No
Hours given ____
Comments

On completion of Section B by the Hall Warden this form must be sent to both the University Fire Officer and Campus Living –see below

Section C- Health and Safety office use only

Incident closed / Yes No

Circulation:

On completion circulate the form to University Fire Officer & imago Health and Safety Co-ordinator:

1) E-mail to , or,

2) Fax to 01509 223904, or,

3) Post to: R.M.Harrison University Fire Officer, Health and Safety office, FM Building, Loughborough University, Loughborough, LE11 3TU

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Health and Safety Office

Revised by: R Harrison – September 2018This document forms part of the Health & Safety Policy