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 contractor. It should be used to bring to the attention of the school any near miss or incident arising out of work being undertaken at or on behalf of the school which could have resulted in injury. The form must NOT be used for reporting accidents where people were injured. The school 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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Forename(s).
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Surname.
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Category of Person or Staff (choose 1 option).
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If Other - Give more details.
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Address
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Phone.
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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Describe what happened?
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What immediate actions were taken at the time?
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What actions have been taken since 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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Name and signature of person reporting the event
7. E-mail the completed form to:
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'Export' the completed form directly by e-mail to a member of the senior management team for approval
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:
