Incident report form Pt.A

• Incident No.

• Incident Reported by:

• Reporter's Contact Number

• Position:

  Student

  Mentor

  Visitor

• Team Group:

  Mechanical

  Software

  Media

  Business

• Incident Date and Time

  Date

• Members Present

• Person(s) Affected (if different from person reporting)

• Location
  Address

• Off or On campus

  On Campus

  Off Campus

• If off campus, site contact namer:

• If of campus, site contact number

Incident Type

• Was the incident caused by human error?

  Yes

  No

  N/A

• Incident type

  Select Electrical Shock Heat Injury Chem. Spill Tool Injury Slip/Trip/Fall Collision with another Person Collision with an Object Struck by Robot Psychological Near Miss

  • Electrical Shock
  • Heat Injury
  • Chem. Spill
  • Tool Injury
  • Slip/Trip/Fall
  • Collision with another Person
  • Collision with an Object
  • Struck by Robot
  • Psychological
  • Near Miss

Was anyone injured?

• Turn on if Applicable

  Off

  On

• Name of injured person:

• Date of Birth

  Date

• Residential Adress:

• Contact Number:

• E-Mail Adress

• Injury reported to:

• Date Reported

  Date

Initial Treatment Given by:

• First Aid Officer (name):

• Details of Treatment: