Title Page
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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 security@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.
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Date of Accident.
2. Department / Service / Hall etc.
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Dept / Service / Hall etc.
3. Personal Details.
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Title.
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Forename(s).
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Surname.
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Age.
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Sex.
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Current Residential Address..
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Post Code.
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Category of Person or Staff (choose 1 option).
- Academic and related
- Academic and related
- Cleaning / Domestic
- Security
- Student
- Visitor
- Administrative
- Grounds / Gardening
- Technical
- Undergraduate
- Contractor
- Catering
- Maintenance
- Other Staff
- Postgraduate
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Contractor's Employer and Address.
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Phone.
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E-mail address.
4. Description and Severity of Injury or Illness
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EG. fracture, cut finger, dermatitis, and location - state left/right
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Severity (choose 1 option).
- Absence for first aid treatment only
- Less than 3 days absence
- * More than 3 days absence
- * Major injury
- * Fatality
- Absence not yet known
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* Statutorily reportable incidents University Health, Safety and Environment Office to be notified immediately by telephone (ext. 2180/2181).
5. Treatment.
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Name of person providing first aid.
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Description of local first aid treatment given.
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Other medical treatment
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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.
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I allow photograph(s) to be taken of the injury and immediate surrounding area.
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Photograph of the injury/illness showing where possible the severity and location on the body.
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Photograph of the surrounding area showing where possible the circumstances that led to the accident / incident.
6. Details of accident.
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Date and Time of the accident.
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Building name.
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Room name / number.
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Location type (choose 1 option).
- Building communal area
- Workshop
- Sports area
- Sports facility
- Office accomodation
- Catering area
- Laboratory - research
- Laboratory - teaching
- Residential Hall
- Road / footpath / campus area
- Other
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If 'Other', please specify
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What caused the injury?
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Description of the agent(s) involved.
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What was the injured person doing?
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What was the incident and how did it happen?
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Names and addresses of witnesses:
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Person supervising work (for Contractor include Loughborough University Co-ordinator).
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Incident reported to (title, initials, surname).
7. Absence.
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On the day of the accident between what hours was the injured person expected to work?
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From: DD/MM/YYYY
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To: DD/MM/YYYY
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Actual hours worked:
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From:
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To:
Preventative action taken and comments by Reporting Officer.
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Preventative action taken and comments by Reporting Officer.
Signatures
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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
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Signature of injured person.
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Signature of reporting officer.
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Signature of Head of Department or their representative.
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'Export' the completed form directly by e-mail to 3 recipients:
Securityservicemanagers@lboro.ac.uk and hse@lboro.ac.uk and Security@lboro.ac.uk
