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Incident Reporting

Report of an Accident, Dangerous Occurrence or Incident

Notices & Guidance:

Information submitted on this form may, under certain circumstances, be used as evidence in dealing with insurance claims. By submitting this form you are providing your consent for your details to be used if necessary for the reason outline above. All personal information will be treated under the terms of the Data Protection Act 1998.

Any 'Email Address' entered in this form will ensure an electronic copy of this accident/incident report is sent to the specified address. Please ensure you only enter valid email addresses in the normal NameA@ed.ac.uk format.

Any field below having a red asterisk * to the right of it is mandatory and must be completed.

The (i) symbol is a link to further, relevant information.

After submitting this form you will be presented with a printable copy ('carbon copy') for your records.

Please click here for the full Guide to completing an Incident Report.

Training on how to report an accident or incident is available from our Training Unit, please see Accident Reporting Training for more information.

A

Date, time and place of accident, dangerous occurrence or incident?

Date of Incident:

(dd/mm/yyyy) *

Time of Incident:

(24hr - 00:00) *

Location of Incident:

(i ) * (Please enter name of building as well as room no)

School/Planning Unit:

* (Enter School/Unit where IP works)

Dept/Sub Unit:

(Enter Dept/Sub Unit if applicable)

If 'Dept/Sub Unit' not in list, please specify:

Other:

B1

The person injured or involved in the accident, incident etc.

Firstname(s):

Surname:

Building/Street:

Town/City:

Postcode:

Home Tel:

UoE Direct Dial No:

Email Address:

(Name@ed.ac.uk)

Age:

Sex:

Status:

If 'Any Other Status', please specify:

Other:

Job title

Nature of injury/condition:

( i )

Part(s) of body affected;

( i )

Is this accident likely to result in the injured person being absent from work?

Absence Likely:

( i )

If known, first date of absence from work:

Absence Date:

(dd/mm/yyyy)

B2

School, etc. Safety Advisor (if known) , Line Manager or Supervisor.

Full Name:

( i )

UoE Direct Dial No:

Email Address:

(NameA@ed.ac.uk; NameB@ed.ac.uk etc)

C

Management of Injury (please select an appropriate choice from the menu).

Injury Management:

( i )

D

Full account of accident, dangerous occurrence or incident (Use the box provided below).

Please describe what happened and how. In the case of an accident state what the person injured was doing:

Description:

Details of any witnesses (if known) to accident, etc.

Witness 1 -Full Name:

UoE Direct Dial No:

E

Remedial action at Management Unit / School, etc level.

Any defect in a building associated with an accident must be reported to Works Division - further information is available at the following Web address:- http://www.estates.ed.ac.uk/FaultReport/index.html Use the box below to provide details of any remedial action taken / required to prevent a recurrence:

Prevention:

( i )

F

Details of the person making this report.

Full Name:

Email Address:

* (NameA@ed.ac.uk; NameB@ed.ac.uk etc)

UoE Direct Dial No:

Date of Report:

(dd/mm/yyyy)