ACCIDENT or DANGEROUS OCCURRENCE REPORT (S1) FORM

For use by Safety Services
Completing and signing this form does not constitute an admission of liability of any kind, either by the
person making the report or by any other person.

If more than one person was injured in the accident, please complete a separate form for each person.

Please read the Guidance Note before completing and write clearly in BLOCK CAPITALS and black ink.
Ref:
Date
Received:
Safety
Adviser:
F2508
Yes / No
The Data Protection Act 1998 requires the University to inform you that the data on this form will be used for the purposes of
improving the management of health and safety in the University and in accordance with legislative requirements.
A Subject of report:
Accident
Dangerous Occurrence
Fire
Occupational Ill Health
B Date of incident:
Time of incident:
Building:
Exact Location:
(Building, Room No, Area etc.)
If off campus, please specify:
C Injured person or person involved in dangerous occurrence:
First Name:
Male
Female
Surname:
Home Address:
DOB or Age:
Tel No:
Postcode:
Department:
University Employee
Occupation:
Student
Course/Year:
Contractors’ Employee
Member of Public
Other
Contractor:
Purpose of visit:
Please specify:
Nature of injury/ill health condition:
(e.g. cut, bruise, dislocation, skin rash, respiratory illness, etc.)
Part of body injured:
(Indicate left or right, if applicable)
D Indicate what led to the injury, ill health condition or dangerous occurrence (indicate all boxes which apply)
E
Contact with electricity
Hit by a moving/flying/falling object
Contact with moving machinery or material
Hit something fixed or stationary
Drowned or asphyxiated
Injured by an animal
Exposed to an explosion
Injured while handling, lifting or carrying
Exposed to fire
Injured during work/course sports activity
Exposed to/contact with harmful substance
Slipped, tripped or fell on same level
Fall from height: ……….. metres
Trapped by something collapsing
Fall on stairs: No. of stairs: ………..
Physically assaulted by a person
Hit by moving vehicle
Other. Please specify:
Return to work/studies within 24 hrs?
Yes
No
If no, give dates of absence From:
First aid given?
Yes
No
Please specify treatment:
Taken to hospital?
Yes
No
Please specify treatment:
If taken to hospital, detained for over 24 hrs?
Yes
No
If yes, specify period:
University of Strathclyde Safety Services
Useful Learning in a Safe Environment
to:
F General details of the accident or dangerous occurrence
To be completed and signed by the injured person, a witness to the accident or dangerous occurrence (if the injured
person is not available) the first-aider in attendance, if applicable, or by the Departmental Safety Convener. If
necessary, continue on a separate sheet of paper.
Explain what activity the person was engaged in at the time of the accident or dangerous occurrence, what
equipment, if any, they were using and what happened.
Completed by
(Signature)
(Print Name)
Contact Tel No.
Date
Email:
G Action taken to prevent recurrence following the accident investigation
To be completed and signed by the Departmental Safety Convener. If necessary, continue on a separate sheet.
Briefly explain what you found to be the underlying cause of the accident/dangerous occurrence, and what action has
been or will be taken (with timescale and by whom) to prevent a recurrence of a similar incident. Comment on
whether sufficient risk assessments, information, supervision or training were in place at the time and comment on
any review or changes to prevent recurrence.
Departmental Safety Convener
(Signature)
Tel Ext No.
(Print Name)
Date
Email:
University of Strathclyde Safety Services
Useful Learning in a Safe Environment