Information
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Please Select Facility To Be Inspected
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Conducted on
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This form may be used by any member of staff, student, visitor or member of the public. It should be used to bring to the attention of the University any near miss or dangerous occurence arising out of work being undertaken at or on behalf of the University which could have resulted in injury. The form must NOT be used for reporting accidents where people were injured. The University Accident Report Form should be used in such cases.
1. Date and time of the Incident.
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Date and time of the incident.
2. Location (please be as accurate as possible).
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Location.
3. Details of Person Reporting.
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Title.
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Forename(s).
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Surname.
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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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If Other - Give more details.
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Phone.
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E-mail address.
4. Description of the Incident. Please use this section to record the near-miss or incident, or to make a comment or suggestion for improvement
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Why do you consider the near-miss or incident dangerous?
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What immediate action have you taken following the near-miss or incident to prevent a similar occurrence?
5. Photograph(s) of the area and/or results of the near-miss or incident.
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Photograph of the surrounding area showing where possible the circumstances that led to the near-miss or incident. Also to show the results of the near-miss or incident.
6. Signatures
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Signature of reporting officer.
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Signature of Head of Department or their representative.
7. E-mail the completed form to:
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'Export' the completed form directly by e-mail to:
Sportsdutymanagers@lboro.ac.uk and hse@lboro.ac.uk
To be completed by the University Health and Safety Service
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Form received by:
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Date:
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Action taken:
