University of Wolverhampton Accident and Near-Miss Reporting System

INCIDENT DETAILS

*Incident date :
*Incident time (24 hours):
*Incident location (e.g. room number):
*Building :
*Campus :
*Incident type :
No. of witnesses :
Witness names :

PERSON AFFECTED

*Full name :
*Status :
Role (where staff):
*Faculty/Service Department :  
If other :
*Gender :
*DOB :
Nature of Injury :
No inury
Bruise
Sprain/strain
Abrasion/graze
Cut/laceration
Burn
Puncture
Crush
Fracture
Amputation
Scalping
Loss of sight or reduction in sight
Loss of consciousness
Overdose
Pain

Other injury:
Area(s) affected : (please click on the text links or area on the body map)
Right ear
Right eye
Right shoulder
Right upper arm
Right elbow
Right forearm
Right wrist
Right hand
Right fingers
Right thumb
Right hip
Right upper leg
Right knee
Right lower leg
Right ankle
Right foot
Right toes
Right sole
None
Head top/front
Head back
Face
Neck front
Neck back
Chest
Abdomen
Groin
Upper back
Middle back
Lower back
Buttocks
Left ear
Left eye
Left shoulder
Left upper arm
Left elbow
Left forearm
Left wrist
Left hand
Left fingers
Left thumb
Left hip
Left upper leg
Left knee
Left lower leg
Left ankle
Left foot
Left toes
Left sole
If the injury was to a different area please state :
Was the Person affected treated at hospital?
Were they detained in hospital over 24 hours? :
*Person affected's address :

Person affected's phone number :

Person affected's email address :

If member of public - Next of kin contact :
If Person affected is not a University employee or student, please provide:
Employer details :
Reason for being on site :
If Person affected is not completing this report, please provide:
Your name:
Your contact details:

(You can upload photos after submitting this report)


INCIDENT DESCRIPTION

Brief description including any action taken

 

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