Accident, Incident and Near Miss
Reporting Form
IMPORTANT: Please send this form to: Phil Bowtell, Health & Safety, M606, Sixth
Floor, Melbury House, 1-3 Oxford Road, Bournemouth, Dorset BH8 8ES
If staff, please also forward a copy of this accident/incident report form to your Local H&S
Coordinator (a list can be found on the H&S Intramap – accessible via the Staff Portal).
If the accident/injury has resulted in serious injury, please report it immediately to Health
& Safety by phoning (01202) 9 61213 or 07720 948634.
NAME (person completing form):
Phone:
Date:
DETAILS OF INJURED PERSON
Name ……………………………………………………………………. Contact Phone No ………………………
Staff / Student / Visitor / Contractor / Other…………………………………………………………..……..
School/Prof Service (staff & students) ……………………….……………………...
[Male] or [Female]
Job Title ……………………………………………… Course Title (if student) ………………………………………
THE INCIDENT / ACCIDENT / NEAR-MISS
Date ……………………….
Time………………. Place ……………………………………………………………
Describe exactly what happened (include details and location of any injury e.g. cut to right finger);
Was the injured person treated by a BU First Aider?
Yes / No / Don’t Know / Not applicable
(If Yes) Name of First Aider ……………………………………..………………………………..………………………
Treatment Given/Action Taken….…………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
Ensure both pages of this form have been completed prior to submitting
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HSE ACCIDENT CLASSIFICATION
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Slipped tripped or fell on the same level
Injured while handling, lifting or carrying
Hit by something moving, flying or falling
Hit against something fixed or stationary
Fell from a height (how far? …………………………..)
HSE INJURY CLASSIFICATION
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(Tick as appropriate)
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Contact with moving machinery
Exposed to a harmful substance
Contact with electricity
Physically assaulted by a person
Another kind of accident ………………………..
(Tick as appropriate)
a major injury or condition (e.g. Fracture, dislocation,
loss of sight, electric shock)
an injury that incapacitated the person for more
than 3* days (* subsequent to submission of this
form, the H&S Team MUST be notified where this
period exceeds 7 days)
an injury which required them being taken straight
to hospital
none of the above
Did the injured person
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become unconscious?
need resuscitation?
remain in hospital for more than 24 hours?
none of the above.
Names and phone numbers of any witnesses
………………………………………………………………..
Other BU departments or external bodies notified
………………………………………………………..
……………………………………………………..
ACCIDENT INVESTIGATION & PREVENTION (THIS SECTION MUST BE COMPLETED)
Has an investigation been carried out? (and if not, why?)…………………………………………………
Is photographic evidence provided? (and if not, why?)………………………….…………………………
If ‘Yes’, by whom and what were the conclusions? …………………………………………………….….
……………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
Was the activity covered by a Risk Assessment? (Yes/no/other) …………………….…………………..
If ‘Yes’ does it need revising? [YES] or [NO]
If ‘No’ is one required? [YES] or [NO]
Any other comments you wish to make to complete your report:
……………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
N.B. Managers need to be advised of incidents/accidents within their area of responsibility so they
can ensure adequate investigations and risk assessments are conducted.
Note: The information given may be passed onto the Health & Safety Executive ‘HSE’ (where this is required
under our statutory obligations) as well as to the University’s Insurers (in order to advise on risks and claims
matters) and the HR Department (in order to give supporting information with regards to accidents, injuries
and illness), as well as relevant BU Managers and the Health & Safety Committee (to discuss general accident
prevention strategies). Wherever possible anonymity will be preserved.
I:Health & Safety/Public/Accidents & Emergencies/New Accident Form.doc Rev: 04/12
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