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 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, 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.






Current Residential Address..

Post Code.

Category of Person or Staff (choose 1 option).

Contractor's Employer and Address.


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?



Actual hours worked:



Preventative action taken and comments by Reporting Officer.

Preventative action taken and comments by Reporting Officer.


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: and and

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.