EXPLANATORY  NOTES

These notes are provided to assist supervisor/responsible person in charge with the completion of Accident Form (AC1)

The University's definition of an ACCIDENT/DANGEROUS OCCURRENCE/NEAR MISS is, an unplanned event, including physical violence, which may or may not result in injury or ill health to individuals, damage or loss of property, plant, materials or damage to the environment.

SECTION 1

Requires the details of the person who was involved in the incident.  These details should be completed as fully as possible to ensure that if necessary the person can be contacted.  Please note where there is more than one casualty a separate AC1 form should be completed for each person.

"Status" - delete as applicable.  For a student please state whether an Under Graduate or Post Graduate.  As well as their Course Title, Year and Department details which can be stated under the "Job Title or Occupation" category.

SECTION 2

The "full postal address of the building" where the accident occurred can be found inside the front cover of the A4 size departmental Accident Reporting Book.

"Give full account of how accident/incident occurred and, if applicable, how person was injured?"  
Briefly explain the events immediately prior to and during the incident.  Anything which may have influenced the incident should be included e.g. weather conditions, environmental conditions, motility of individual, suitability of clothing/footwear, personal protective equipment etc.

"Details of Structural/Material damage/Loss sustained".  These details should include items such as work equipment, personal protective equipment, glassware, flooring, doors, windows etc. which were being used at the time or were affected directly by the incident.

SECTION 3

"Where was the treatment given"
e.g. At Scene, or the QUB department e.g. University Health Service (UHS) or the hospital i.e. BCH, RVH, Ulster etc.

"Details of treatment given, if known" e.g. R.I.C.E. applied, dumbell stitches used to close wound, pressure pad applied and secured with a bandage etc.

"Who administered treatment".  Person's name (if a member of QUB staff) or title (if an outsider e.g. Paramedic, A&E Nurse, hospital doctor).  If it is a member of the public who is qualified and offers assistance then their name and address should be obtained, if possible.  First Aiders should keep their own separate, written record of all treatment given to injured parties.

SECTION 4 and 4(a)

If anyone else, i.e. witnesses, actually saw or heard what happened, they should be asked to give a brief statement, along with their name, address and telephone number (so they can be easily contacted again) to the person investigating the incident.  It is important that the witness then checks the accuracy of the written statement and if agreeable initials or signs the form to confirm this.

This information may be of great assistance to the investigation as it may elucidate additional circumstances relevant to the incident.

SECTION 5

This section must be completed as part of the investigation.  When considering the "immediate measures taken to prevent a recurrence", it should be noted that other activities or equipment, which could cause or contribute to a similar situation elsewhere in that department should also be considered, and relevant details included with the proposed changes stated.

The questions relating to Risk Assessment are included to ascertain if the department is complying with the Management of Health and Safety at Work Regulations (Northern Ireland) 2000 and as a reminder that the relevant documents may need to be reviewed as a consequence of the accident.