Accident Incident Report Form Page 2
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2xii
Details of injury/damage:
Indicate type of injury (put an ‘x’ in one box only)
Bruising, contusion
Suffocation, asphyxiation
Concussion
Gassing
Internal injuries
Drowning
Open wound
Poisoning
Abrasion, graze
Infection
Amputation
Burns, scalds and frostbite
Open fracture (i.e. bone exposed)
Effects of radiation
Closed fracture
Electrical injury
Dislocation
Property damage,
Sprain, torn ligaments
Specify____________________
Other, Specify_____________________
xiii
Indicate part of body most seriously injured (put an ‘x’ in one box only):
Head, except eyes
Fingers, one or more
Eyes
Hip joint, thigh, knee cap
Neck
Knee joint, lower leg, ankle
Back, spine
Foot
Chest
Toes, one or more
Abdomen
Extensive parts of the body
Shoulder, upper arm, elbow
Multiple injuries
Lower arm, wrist, hand
Other, Specify_____________________
xiv
Consequences of the Accident/Incident:
Anticipated absence if not
Date of resumption of work
back
Fatal
if back
4-7 days
Non Fatal
Year
Month
Day
8-14 days
____
_____
___
More than 14 days
xv
Treatment:
xvi
Doctor’s report and recommendation:
xvii
Steps taken to prevent reoccurrence of this type of Accident/Incident:
Signature of person completing report:
Date:
Print Name & Job Title:
Signature of Head of Department/School/Function:
Date:
Print name:
(Copies of the completed Institute Accident Report are to be sent separately to the Institute Health & Safety
Co-ordinator, the Vice President for Finance & Corporate Affairs and the Estates Office)
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