Incident Report Form

Important notice, in the case of an ongoing emergency please contact Campus Security at: 020 8392 3333.

Please complete this form as accurately as you are able to for RSU to investigate the incident. Be as detailed as possible, and report incidents within 24 hours of their occurance.

Which are you reporting

Which are you reporting Minor injury Major injury Treatment administered Near miss Illness
Name of person completing form Name of person completing form First Last
Relationship to the Society
Email

Confirm Email Address
Date of the event Date of the event / DD / MM YYYY
Location of the event
Person(s) involved
Name: Student ID: Relationship to event (e.g a Society Member, or a Instructor): *Repeat field if necessary
Describe what happened - any tasks performed, and the sequence of events that led to injury, illness, or near miss
Was the incident caused by an unsafe act (such as the activity itself, movement) or unsafe condition (such as using machinery/equipment, or weather)?

Was the incident caused by an unsafe act (such as the activity itself, movement) or unsafe condition (such as using machinery/equipment, or weather)? Unsafe act Unsafe condition
Describe the injury that was caused to the person(s) involved and the specific treatment administered
Injury: Treatment: