University of Bristol Students’ Union - Accident & Incident Report Form

This form is to be used any student activity group (sports club, society, volunteering project etc) to record an accident, incident, dangerous occurrence or near miss. It must be completed as soon as possible after the incident and forwarded to UBU at the earliest opportunity.

Name of student activity group

Names of person(s) involved in accident/incident

/

Address

/

Phone number

/

Email address

/

U Card number

Date of Incident / Time of Incident

Location of accident/incident, including address and postcode (where known)

Nature of accident/incident (tick all that apply)
□  Assault
□  Road Traffic Collision (RTC)
□  Injury/ill health to staff
□  Injury/ill health to student
□  Injury/ill health to contractor
□  Injury/ill health to other person
□  Breach of policy, procedure, guidance
□  Involved hazardous substances / □  Fire/explosion
□  Involved multiple casualties
□  Lack of training/experience
□  Person/s lost Trip – UK
□  Trip – overseas
□  Violence/aggression
□  Equipment failure
□  down / □  Manual handling
□  Machinery failure/break
□  Person colliding with vehicle
□  Failure of/failing to wear PPE
□  Fall from height
□  Slip, trip or fall
□  Confined space
□  Other

Description of accident/incident and extent of injury (please give as much detail as possible)

Was this an accident/incident/dangerous occurrence or near miss
□  Accident / □  Incident / □  Dangerous occurrence / □  Near miss

Description of immediate action taken

Details of any follow up action taken
□  None / □  Taken to hospital / □  First aid/medic
□  Seen by doctor / □  Seen by physiotherapist / □  Other
Details of any witness(es) and their statement(s)
Witness 1:
Name: / Home address:
Statement:
Signature: / Date:
Witness 2:
Name: / Home address:
Statement:
Signature: / Date:
Details of person completing the form:
Name: / Position in club/society:
Signature / Date:

Once completed please send this form to Bristol SU – Central Operations.

Email:

Post: Student Services Team, The Richmond Building, 105 Queens Road, Clifton, Bristol BS8 1LN

------

OFFICE USE ONLY

Name: / Signature: / Date:
Action Taken: