• This form can be used by anyone to report an accident or a case of ill health. It can be filled out by the individual(s) directly concerned or their represntative.

    Once completed the Accident Report Form should be forwarded via e-mail to the Departmental Safety Officer (reporting officer) at Sportsdutymanagers@lboro.ac.uk for signing.

    The reporting officer shall also forward, via e-mail the signed Accident Report Form to the University Health and Safety Service Office at hse@lboro.ac.uk, even if all details are not immediately available.

1. Date of Accident.

  • Date of Accident.

2. Department / Service / Hall etc.

  • Dept / Service / Hall etc.

3. Personal Details.

  • Title.

  • Forename(s).

  • Surname.

  • Age.

  • Sex.

  • Current Residential Address..

  • Post Code.

  • Category of Person or Staff (choose 1 option).

  • Contractor's Employer and Address.

  • Phone.

  • E-mail address.

4. Description and Severity of Injury or Illness

  • EG. fracture, cut finger, dermatitis, and location - state left/right

  • Severity (choose 1 option).

  • * Statutorily reportable incidents University Health, Safety and Environment Office to be notified immediately by telephone (ext. 2180/2181).

5. Treatment.

  • Name of person providing first aid.

  • Description of local first aid treatment given.

  • Other medical treatment

  • Ask the injured person if they will allow a photograph to be taken of the injury. Advise them that the photograph will be used to support the verbal/written information detailing the circumstances of this specific accident/injury/illness/incident. The injured person will be required to sign the form if they give their approval for a copy of the report form containing any photographs may be communicated to a third party, including line management and official Trade Union Representatives.

  • I allow photograph(s) to be taken of the injury and immediate surrounding area.

  • Photograph of the injury/illness showing where possible the severity and location on the body.

  • Photograph of the surrounding area showing where possible the circumstances that led to the accident / incident.

6. Details of accident.

  • Date and Time of the accident.

  • Building name.

  • Room name / number.

  • Location type (choose 1 option).

  • If 'Other', please specify

  • What caused the injury?

  • Description of the agent(s) involved.

  • What was the injured person doing?

  • What was the incident and how did it happen?

  • Names and addresses of witnesses:

  • Person supervising work (for Contractor include Loughborough University Co-ordinator).

  • Incident reported to (title, initials, surname).

7. Absence.

  • On the day of the accident between what hours was the injured person expected to work?

  • From: DD/MM/YYYY

  • To: DD/MM/YYYY

  • Actual hours worked:

  • From:

  • To:

Preventative action taken and comments by Reporting Officer.

  • Preventative action taken and comments by Reporting Officer.

Signatures

  • I hereby allow / do not allow a copy of the information contained within this report to be communicated to a third party, including line management and official Trade Union Representatives

Sign Off

  • Signature of injured person.

  • Signature of reporting officer.

  • Signature of Head of Department or their representative.

  • 'Export' the completed form directly by e-mail to 3 recipients:
    Sportsdutymanagers@lboro.ac.uk and hse@lboro.ac.uk and L.Davies2@lboro.ac.uk

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