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 :
Incident type other/details :
No. of witnesses :
Witness names :

PERSON AFFECTED

Full name :
Status :
Role (where staff):
Faculty/Service Department :  
If other :
Gender :
DOB :
Nature of Injury :
Other:
Area(s) of the body affected (please click on the text links below or area on the body map)



































































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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