SUSU Incident Report Form Individual(s) Involved: Type/Nature of ...

SUSU
Incident Report Form
This form is to be completed as soon as possible after any security incident by the
competent person involved and sent to the Duty Manager/Facilities Department who will
distribute it within 1 week of the incident to the Health Safety & Environmental Health
Officer
Any statements from other staff or witnesses should be attached with this report.
Location of Incident:
Manager/Supervisor on Duty
Time of Incident:
Date of Incident:
Time of Completing Report
Date of Completing Report:
Name(s) of Staff Dealing with Incident:
Individual(s) Involved:
Name:
Please Print clearly
Phone Number:
Address:
Type/Nature of Incident: Please tick
Accidental injury
Sporting Injury
Accidental damage
Vandalism
Break In/Theft
Evacuation
Personal Safety
Racist/Sexist/Homophobic Conduct
Unacceptable/Anti-Social Behaviour
Violent Conduct
Near Miss
Other
Please state: …………………………………………………………………………
Emergency Services Called? Fire Yes No
Ambulance: Yes No
Police: Yes No

If police called, give name of station and crime number if applicable.
University Security Called? Yes No
If yes, give name of officer:
CCTV Tape requested? Yes No
Evidence Taken (please take as much evidence as possible. E. G photos)
Yes No
If yes, please state type of evidence received … … … … … … … … … … … … … … …
… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … …
Was anyone injured? Yes No
If yes, please complete and attach an accident form
Was there any damage to property? Yes No
If yes, please give details:
Owner: ……………………………………………………………………………………………
Damage: …………………………………………………………………………………………
Property: …………………………………………………………………………………………
Description of Incident:
Describe the events leading up to during and after the incident
Witnesses: (Please list the names, addresses, union card numbers, etc
including any security staff)

Who do you consider was responsible for the incident?
What if anything could have been done to prevent the incident?
Do you recommend any follow up?
Completed by
(print):
Signed:
Position:
Send form to DM/Facilities Office for distribution: Pres / GM /HS&E Officer