EmailMe Form - Accident Report Form

When did the accident/occurrence take place *

DD / MM / YYYY HH : MM AM/PM

Place of Accident/Occurrence *

(Campus/Building/Room)

Exactly where at that place *

Activity in progress at the time *

What happened? *

Name of Injured Person or Persons Involved *

Age *

Occupation

Gender *

Male

Female

Other

Prefer not to say

Who are they? *

Address

(If not a student or employee)

Nature of Injury (and Part of Body Injured): *

Treatment Given *

Was an Ambulance Called? *

Yes

No

If yes, What was the call sign?

Was the injured person taken to hospital? *

Yes

No

Did absence result from the accident? *

Yes

No

Unknown

Names of Any Witnesses

(and contact details if not a Brunel student or employee)

Action Taken or Recommended to Prevent a Recurrence *

Person Making the Report *

Occupation *

Tel No *

(If not a member of Union staff)

Terms and Conditions *

I have read and agreed to the Union's terms and conditions and privacy policy regarding the use of my details and data.

See https://brunelstudents.com/termsandconditions/