Accident and Incident form

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 Firstname.Surname@ed.ac.uk format.

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

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

Full guidance on how to complete the online form is available as a PDF. Training is also available, please see our Training section for more details.

Section A

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

Date of incident
Time of Incident:	(24hr - 00:00) *
Location of Incident:	(Please enter name of building as well as room no)
School/Planning Unit:	* (Select School/Unit where injured person works)
Dept/Sub Unit:	(Select Dept/Sub Unit if applicable)
If 'Dept/Sub Unit' not in list, please specify:
Other:

Section 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:
E-mail Address:	(Name@ed.ac.uk)
Age:		Sex:
Status:
If 'Any Other Status', please specify:
Other:
Job title:
Nature of injury/condition:
Part(s) of body affected:
Is this accident likely to result in the injured person being absent from work?
Absence Likely:
If known, first date of absence from work:
Absence Date:

Section B2

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

Full Name:		UoE Direct Dial No:
Email Address:	(NameA@ed.ac.uk; NameB@ed.ac.uk etc)

Section C

Management of Injury

Please select an appropriate choice from the menu.
Injury Management:

Section D

Full account of accident, dangerous occurence or incident

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:

Section E

Remedial action at Management Unit/School, etc level.

Any defect in a building associated with an accident must be reported to Works Division:

Fault Reporting

Use the box below to provide details of any remedial action taken / required to prevent a recurrence:

Prevention:

Section 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:

This article was published on Jul 4, 2011