Preview Injury Incident Form

ACCIDENT / INCIDENT REPORT FORM

Note:

This form should be completed whenever an accident or incident occurs which results in injury or damage to

personnel or property.

If personnel or property WERE NOT injured or damaged during the Accident/ Incident, do not use this form.

Use the NEAR MISS REPORT FORM.

Accident / Incident Report Form

Name of person involved in

Accident/Incident:

Address:

Phone:

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Who was involved in the Accident/Incident:

 Student  Employee  Public  Contractor Visitor

Occupation:

If an employee of the Institute please state Department:

If no, please elaborate:

vii

Particulars of Accident/Incident & circumstances under which the Accident/Incident occurred:

Use additional pages and/or photos if necessary.

viii

Place:

Time:

Date:

Witness Phone No & Address:

When and to whom was the Accident/Incident initially reported?

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