My Apps
Search
Sign In
Accident and Near Miss Form
Forms
Involved Party Information
First Name
Last Name
Email Address
Affiliation with UMass Lowell
Please select...
Student
Faculty/Staff
Other
Phone
If Other, please specify
Name of Principle Investigator / Supervisor (or N/A)
Was a person working as an employee at the time of the incident?
Yes
No
Incident Details
Accidents
- An event that
did cause
harm.
Near miss
- An event that
could have caused
harm but didn't. (ex: a chemical spill that splashes near someone's eyes but they're wearing goggles, so no injury occurs)
Please select type of incident
Please select...
Accident
Near Miss
Date of incident
Time of incident
Department
Location (building and room)
Please describe the incident
Was there a witness?
Yes
No
Witness Name
Witness Phone Number
Were there any injuries?
Yes
No
Name of injured person
List any body parts that were injured
Describe the injury
Did you dial 44911 for first aid treatment by EMTs?
Yes
No
Was the person transported off site for treatment?
Yes
No
If yes, where?
Is there a Standard Operating Procedure?
Please select...
Yes
No
N/A
Is there a specific training in place?
Please select...
Yes
No
N/A
