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 firstname.lastname@example.org 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 email@example.com, even if all details are not immediately available.
Dept / Service / Hall etc.
Current Residential Address..
- Academic and related
- Academic and related
- Cleaning / Domestic
- Grounds / Gardening
- Other Staff
Contractor's Employer and Address.
EG. fracture, cut finger, dermatitis, and location - state left/right
- Absence for first aid treatment only
- Less than 3 days absence
- * More than 3 days absence
- * Major injury
- * Fatality
- Absence not yet known
* Statutorily reportable incidents University Health, Safety and Environment Office to be notified immediately by telephone (ext. 2180/2181).
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.
Room name / number.
- Building communal area
- Sports area
- Sports facility
- Office accomodation
- Catering area
- Laboratory - research
- Laboratory - teaching
- Residential Hall
- Road / footpath / campus area
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).
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.
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
'Export' the completed form directly by e-mail to 3 recipients:
Securityservicemanagers@lboro.ac.uk and firstname.lastname@example.org and Security@lboro.ac.uk