ࡱ> kmj{ Hbjbjzz AZ 8 86l5NT}& K5M5M5M5M5M5M5$7:q5-}}q55RK5K5+-;lFw,75505,|;Z; -;-Z@]4q5q5vr5; : THE UNIVERSITY OF READINGINCIDENT REPORT FORMLocal Reference  FORMTEXT      H&S Reference  FORMTEXT      Report of an injury, occupational ill-health, fire or  near miss at work If you are able to access the University web site, please complete the on-line incident report form at  HYPERLINK "http://www.reading.ac.uk/internal/health-and-safety/IncidentReportingandEmergencyProcedures/Report_an_Incident_online.aspx" http://www.reading.ac.uk/internal/health-and-safety/IncidentReportingandEmergencyProcedures/Report_an_Incident_online.aspx Only use this paper form if you are unable to use the on-line version. Once completed, please email to  HYPERLINK "mailto:safety@reading.ac.uk" safety@reading.ac.uk and give a copy to your supervisor or Area Health & Safety Co-ordinator. Section A Who was involved in the Accident/Incident? (If no-one was involved, go to Section B) * required fieldStatus Please tick which applies  FORMCHECKBOX  A ϲʿ¼ employee?  FORMCHECKBOX  A student: Undergraduate?  FORMCHECKBOX  Postgraduate?  FORMCHECKBOX   FORMCHECKBOX  Other (please specify)  FORMCHECKBOX  Member of the public  FORMCHECKBOX  A contractor or agency worker? Name of person involved or injured. * If no-one was involved, leave blank.Staff or Student Number:Contact telephone number:*Contact email address:*Contact address:Faculty or Service:School/Department:Section B - About the incidentDate and time of incident: What are you reporting?  FORMCHECKBOX  Accident or injury  FORMCHECKBOX  Near miss  FORMCHECKBOX  Illness  FORMCHECKBOX  Dangerous occurrence  FORMCHECKBOX  Fire or fire alarm incident  FORMCHECKBOX  Another type of health and safety issue, please specifyPlease provide brief details of the accident, incident or matter of concern: Address / location where the incident took place: Did the accident, incident or matter of concern result in any of the following? Please tick as many as apply.  FORMCHECKBOX  First aid treatment  FORMCHECKBOX  Visit to GP or University Health Centre  FORMCHECKBOX  Ambulance attended  FORMCHECKBOX  Hospital visit or stay  FORMCHECKBOX  Time off from work or study  FORMCHECKBOX  Damage to University or personal property (e.g. building fabric or equipment)  FORMCHECKBOX  Other (please specify) Section C Remedial action taken Has anyone carried out remedial actions to prevent further problems?  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