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Incident Notification Form
19 June 2013
1.Begin
2.What
3.Where
4.End
Please complete this form as soon after the Incident as possible. Please complete all fields fully and accurately. Please note, mandatory fields are marked with an asterisk (*) and you will not be able to submit the report if these fields are incomplete.
Type of Incident
Type of Incident
*
[Select]
--------
Work-related Injury
Student Injury
Violence at Work
Recreational/Sporting Accident
Taken Ill at Work
Road Traffic Accident
Damage or Loss
Hazard Observation
Near Miss
Fire Incident
Environmental Incident
Person Entering this Report
Please record the name and contact number of the person entering this report.
Name
*
[Max chars : 50]
Contact Tel No.
*
[Max chars : 50]
About the Incident
Please record the time and date of the Incident.
Time & Date of Incident
*
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For which part of UCL does the injured person work. If not known or if there is no injury then which part of UCL does the person reporting this Incident work for?
Division, School, Faculty, Institute:
*
Department:
*
Group/Unit:
*
[
*
Mandatory Field]
