Accident Form

Accident and Near-Miss Report Form

 

This form must be completed immediately after the incident by the responsible person or the injured person if they are able to do so. First aiders and Security should complete the form if they attend.

Near misses and dangerous occurrences can be reported by whoever witnesses the incident or when they first become aware.

If an accident or near-miss takes place at your activity or event and you do not report it, your group may be subject to disciplinary action.

 

Section 1: About the Incident

 

Details of the Incident:

Please provide us with details about the incident.

 

Type of Incident: Near MissPhysical or verbal assaultIllnessExposure to Biological agentsFell from a heightSlipped, tripped or fell on same levelRepetitive strain or postural injuryDrowning / asphyxiationContact from moving machinerySporting InjuryExposed to explosionManual handling or lifting injuryTrapped by something collapsingStruck by moving vehicleExposure to harmful substancesInjured by an animalStruck by objectElectric shockFire/fire alarmStruck against objectAnother kind of incident
 

Date of Incident:  (dd/mm/yy)
 

Time of Incident:  (hh:mm)

 

Did the accident take place on campus?: YesNo

Exact location of incident: 

 

Description of incident (please provide as much information as possible):

 

Was anyone injured?: YesNo

If yes, please provide details:

 

What happened after the incident?:

The person was taken to hospitalThe person returned to work or the activityOther

 

Section 2: About the person involved in the Incident

You can report the incident for yourself or on someone else's behalf. If you are completing the form for yourself please complete your details, otherwise select who you are reporting the incident for and enter their details. 

 

Who are you reporting the incident for?: MyselfAn ARU studentA member of the publicA staff memberA visitorA contractor

Name: 

Email Address:

Contact Number:

SID (if an ARU student: 

Is the person involved in the incident under 18?: YesNo

Section 3: Witnesses

Witnesses can help us get a better understanding of an incident. Enter the details of any witness/s to the incident and we will contact them if required. There's no limit to the number of witnesses you may add though generally 1 or 2 is sufficient.

Was there a witness present?:YesNo

Do you have contact details for the witness(es)?:YesNo

If yes, we may be in touch to request these details. 

 

Before you submit this form:

Please ensure the details you have provided are factual and accurate. Once the form has been submitted changes can only be made by contacting ARU Students' Union.

If you require this form in a different format or if you have any queries about this form, please contact inclusion@angliastudent.com.