• 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.

  • Date and time of the incident.

2. Location (please be as accurate as possible).

  • Location.

3. Details of Person Reporting.

  • Title.

  • Forename(s).

  • Surname.

  • Current Residential Address..

  • Post Code.

  • Category of Person or Staff (choose 1 option).

  • If Other - Give more details.

  • Phone.

  • 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

  • Why do you consider the near-miss or incident dangerous?

  • 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.

  • 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

  • Signature of reporting officer.

  • Signature of Head of Department or their representative.

7. E-mail the completed form to:

  • 'Export' the completed form directly by e-mail to:
    Securityservicemanagers@lboro.ac.uk and hse@lboro.ac.uk and security@lboro.ac.uk
    Please ensure a Perspective Incident report is made

To be completed by the University Health and Safety Service

  • Form received by:

  • Date:

  • Action taken:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.