Responsibility for ensuring that the relevant forms are completed and circulated rests with the relevant Head of School/Department/Section or his/her nominee in all cases.
Note:UCC users are advised that the pdf copies of accident forms provided hereunder are for information purposes only. Please do not download for the purpose of reporting an incident. The official A3 size carbon copy forms are available at Department level and from the Health and Safety Office.
UCC Reporting Forms and Investigation System
The UCC Accident and Dangerous Occurrence Incident Reporting format comprises four discreet forms, comprising staff/non-staff report forms and an investigation form. They are as follows:
Form1: Staff Accident Report Form ( Sample - not for use) Form 1 Staff Accident Report Form (to be completed by the School/Department/Section Head or nominee)
Form 3: Non Staff Accident Report From ( Sample - not for use). Form 3 A Non Staff Accident Report Form (to be completed by the injured person and the School/Department/Section Head or nominee)
Form 2: Dangerous Occurence/ Near Miss Incident Report Form ( Sample - Not for use)Form 2 A Dangerous Occurrence/ Incident Report Form
Form 4: Incident Investigation Report Form ( Sampe - not for use)Form 4 Accident/Dangerous Occurrence Investigation Report Formto be completed by the relevant School/Department/Section Head or nominee in all cases - subject to an exemption for incidents of a very minor or superficial nature which could not have resulted in more serious consequences and which have been reported in full using Forms 1,2 or 3 as appropriate.
For expediency, forms 1,2,&3 refer the reader to classification codes (Please see updated classification document following below of Q4 2015 which superceeded that previously issued to all UCC Departments). These relate to the pre-selection of regular descriptive data with respect to the following:
(a) Type of injury
(b) Parts of body most seriously affected
(c) Type of Dangerous Occurrence
(d) Incident locations
Each form is produced in a colour coded multiple carbon copy format. Circulation instructions are summarised in the next section.
Note: Serious accidents or serious dangerous occurrences should be immediately reported to the School/Department Safety Officer. Such incidences should also be immediately phoned through to the relevant Head of Function/College, the Insurance & Claims Officer and the Risk Management Officer at extension 2800 (both c/o of Office of Corporate & Legal Affairs), General Services Supervisor and to the University Safety Officer at extension 2817