Report an Incident

Please fill out this form to report a health & safety incident. Once the form has been submitted, a member of the Facilities Team will be in touch should any follow-up actions be required

Asterisk (*) indicates a required field.

Section A - Injured Person’s Details

Name*

Incident Type?*

Section B - Manager’s Details

Manager Name*

Manager Department*

Manager Email*

Manager Extension No.

Section C - Accident Details

Date/Time Accident Occurred*

Location*

Describe what happened*

Who was injured or suffered ill-health?*

What injuries or ill-health effects were caused?*

Were there any witnesses?*

Section D - Investigation

How did the accident happen?*

What activities/tasks were being carried out at the time of the accident?*

Was there a risk assessment covering the activities/tasks being undertaken?*

Were the people involved trained and competent to carry out activities?*

In relation to the working environment and/or equipment involved, was maintenance and cleaning up to date?*

Were witnesses interviewed?*