Accident/Incident Report Form

Division of Informatics Accident/Incident Report Form

Accident/Incident Report Form

Please complete the form to report an accident/incident or dangerous occurence.
Applications without valid information in the compulsory fields (marked *) will be disregarded.

A.
Date, time and place of accident, dangerous occurence or incident.

Date *
Department

Time

Location *

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

Full name *

Address

Age

Sex *
Male Female

Status (please check appropriate box) *
Employee Postgraduate Undergraduate Trainee (YTS) Outside Contractor Visitor Any other person

Job Title, Occupation or Trade

Nature of injury or condition and the part of the body affected. *

C.
Management of injury (Please tick appropriate box)

First aid only Advised to see doctor Doctor called to casualty Casualty sent to hospital Admitted to hospital for more than 24 hours

Full account of accident, dangerous occurrence or incident *

Email address *