Health & Safety Incident Report | Students Union UCL

Required field

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.

Initial Incident Information

Your full name

E-mail address

Contact number

Type of incident

Date and time of Incident

Others involved in incident ?

Yes

Reason for that person to be at the Students' Union or Union Event/Activity

Detailed Incident Information & Location information

Involved Persons details

Full name	number	email	category	involvement	Operations
Full name	number	email	category category Enter other…	involvement involvement Enter other…

Give as much detail as you can, e.g. name any substance or equipment involved, circumstances leading up to Incident, the part played by any people and what the injured person was doing at the time of the Incident.

General location of Incident/Accident

Record about the precise location of the Incident. Include a full description of the nature of the environment.

Room Number (if applicable)

Further Information

First Aider in attendance ?

Yes

Name of First Aider (if yes)

Emergency services requested ?

Yes

Please let us know which emergency service was contacted ?

UCL Security requested/informed ?

Yes

How did you contact UCL security ?

Attachments

By submitting this form, you hereby agree for the Students' Union Health & Safety Team to contact you, and any others who have been involved in an incident.