BACK TO STAFF PORTAL Phone Sender Information Your Email: * Your Name: * Your Surname: * Report of an accident or case of occupational ill-health 1. Date of accident 2. Injured persons - Dept/Section/Hall3. Personal details: Name of injured or ill person Title Forename(s) Surname Age Sex: M / F Current residential address including post code: Phone numbers: Category of person (Staff):(tick one box) Category of person 1 Academic and related Administrative Catering Category of person 2 Cleaning/ Domestic Grounds/ Gardening Maintenance Category of person 3 Security Technical Other staff Category of person 4 Student Contractor Visitor Contractors employer & address: Phone/Fax: 4. Description and severity of injury/ illness e.g. fracture, cut finger, dermatitis, and location – state L/R: Description and severity of injury/ illness: Severity (tick appropriate box): Severity 1 Absence for first aid treatment only Major injury * Severity 2 More than 7 day absence* Less than 7 days absence Absence not yet known 5. Treatment Description of local first aid treatment given: Name of person providing first aid: Other medical treatment: 6. Details of accident Date: Time: Location (Building/Room/Area): What was the injured person doing? What caused injury? Names and addresses of witnesses: Person supervising work ( for Contractor include LU Project Co-ordinator): Incident reported to (Title, initials, surname): On the day of the accident between what hours was the injured person expected to work? From: To: Actual hours worked: From: To: I hereby allow/do not allow (delete as appropriate) a copy of the information contained within this report to be communicated to a third party, including line management and official Trade Union representatives Signature of person reporting: *
