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  • Incident Report and Investigation Form

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    Christine Kho
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    An incident report form documents an incident involving a staff member at a university. The form collects details about the incident such as the staff member's name and contact information, date and time of incident, location, description of the incident and any resulting injuries or property damage. Witness information is also recorded. The incident investigation section analyzes the root cause and lists control measures to prevent future occurrences. The completed form should be sent to the university's Environmental Health and Safety team and the staff member's Divisional EHS Coordinator.

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    Incident report and investigation form

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    An incident report form documents an incident involving a staff member at a university. The form collects details about the incident such as the staff member's name and contact information, date and time of incident, location, description of the incident and any resulting injuries or property damage. Witness information is also recorded. The incident investigation section analyzes the root cause and lists control measures to prevent future occurrences. The completed form should be sent to the university's Environmental Health and Safety team and the staff member's Divisional EHS Coordinator.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    4 views1 page

    Incident Report and Investigation Form

    Uploaded by

    Christine Kho
    An incident report form documents an incident involving a staff member at a university. The form collects details about the incident such as the staff member's name and contact information, date and time of incident, location, description of the incident and any resulting injuries or property damage. Witness information is also recorded. The incident investigation section analyzes the root cause and lists control measures to prevent future occurrences. The completed form should be sent to the university's Environmental Health and Safety team and the staff member's Divisional EHS Coordinator.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Incident Report and Investigation Form

    Incident Report Section


    Surname: First name: Telephone number:
    Inciden

    person

    Gender: Division/Room No.: Length of employment/study:


    t

    Date: Time: Location of incident (Building & Room No.)

    Was the person authorized there? Incident classification


    Injury □ Ill health Near miss □
    Description
    of incident

    Describe work/activity being performed and the incident:

    Describe injury /property damaged:

    None First aid Hospital More than 1-3 days More than 3 Major injury
    required treatment 24 hours in absence days
    treatment
    Medical

    hospital absence

    Name and address of witness(es):


    information
    Other

    Name of person making report: Telephone:

    Division/Room No.: Date:


    Incident investigation section
    Falls on level/stairs Falls from height
    Struck or trapped by object striking against fixed or stationary object
    Causative agents

    Fire/explosion Electricity
    Sharps Handling/lifting
    Hot/cold contact Defective premises/equipment
    Exposure to toxic substance or pathogen Unintentional chemical spillage
    Work related vehicle/traffic incident Live animal
    Occupational illness Other (Specify)
    Describe the incident cause
    cause
    Root

    Investigated by
    No. Control measures Completion date Due date Responsible person
    measures
    Control

    Investigated by

    Remark: Please send the report to Campus EHS team at EHS@nottingham.edu.cn and your Divisional EHS Coordinator, after completing
    the incident report section.

    Page 1 of 1

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