Accident/Incident Report Form

An accident is an unplanned event that results in an injury or could have resulted in an injury or results in damage to equipment or property OR harm to the environment. Anyone can complete an accident/incident report form. Once completed the form should be sent via the internal mail to the Health and Safety Officer at Malet Street. Electronic copies can be sent by e-mail attachment to: t.mccartney@bbk.ac.uk

Confidentiality - This form will be held securely by the Birkbeck Safety Office for the purpose of monitoring health and safety and will only be disclosed to persons or organisations able to demonstrate a legal right to the data therein.

Details of person completing this report.   
Full name...........................................................................................
Staff/Student/Visitor/Contractor (circle relevant category)
School/Department/Course - if staff or student.............................................................
Address & postcode if visitor or contractor............................................................................................
Telephone contact number........................................................................................
Signature..................................................................... Date...................................

Details of accident/incident
What happened. Give cause (how and why) if known.....................................................
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When it happened: date......................................... time............................................
Where it happened...................................................................................................

Details of any persons injured
Full name...............................................................................................................
Staff/Student/Visitor/Contractor (circle relevant category)
School/Department/Course if staff or student...............................................................
Address & postcode if visitor or contractor...................................................................
............................................................................................................................
Telephone contact number........................................................................................
School/Department/Course........................................................................................
Nature of injury.......................................................................................................
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Treatment given.....................................................................................................
Treatment given by.................................................................................................
Taken to hospital - yes/no
If yes, which hospital and how taken..........................................................................
Off work as a result of accident/incident - yes/no..... If yes - number of days...........

For completion by the Health and Safety Officer
Accident/Incident investigated - yes/no
Written investigation report necessary - yes/no
Written investigation report completed -yes/no
RIDDOR reportable - yes/no. If yes, date reported.....................................
EA/DEFRA reportable - yes/no.  If yes, date reported................................
Charity Commission, serious incident reportable - yes/no.  If yes, date reported.............................

Witness details, statements, etc - continue report overleaf if necessary.

Investigator's guide
In order to determine the cause of the accident or incident, it may be appropriate to interview parties who were involved. First think about the questions you ultimately want to answer, for example:

• a)  Was a safe work procedure used?
• b)  If there were safe working procedures were they up to date?
• c)  If there were safe working procedures and instructions, were they realistic, accurate and adequate?
• d)  If there were safe working procedures, etc were they readily available to those carrying out the work?
• e)  If there were safe working procedures, were they enforced/monitored/supervised?
• f)   Were training needs for the activity identified?
• g)  Was any required Personal Protective Equipment available for use and used?
• h)  Had conditions changed to make the normal procedure unsafe?
• i)   Were the appropriate tools and materials available?
• j)   Were safety devices working properly?
• k)  Were the correct materials/substances being used?