Notification of accidents and incidents – Oficina de Seguretat, Salut i Medi Ambient

You can download and print the document of the Notification of accidents or fill and send the following form.

Form

Fields marked with * are required.

Person reporting the accident

Name and surnames*

NIF or NIE*

Telephone*

E-mail*

Relations with the UB*

Faculty*

Studies to which it is attached

Department, unit or service to which it is attached*

Relation with the accident*Affected personBody responsible for the place or activity where the accident has taken placeWitnessOthers

Affected person

These data are not obligatory, if you consider it appropriate to include them, click on the box. In this case, a copy of the accident notification will be sent to the e-mail address provided.

I want to include the data of the person concernedYesNo

Name and surnames*

Telephone

E-mail*

I want to include another person concernedYesNo

Name and surnames*

Telephone

E-mail*

Body responsible of the place / activity where risk is detected

These data are not obligatory, if you consider it appropriate to include them, click on the box. In this case, a copy of the accident notification will be sent to the e-mail address provided.

I want to include the details of the responsible personYesNo

Name and surnames*

Telephone

E-mail*

Witnesses of the accident or incident

These data are not obligatory, if you consider it appropriate to include them, click on the box. In this case, a copy of the accident notification will be sent to the e-mail address provided.

I would like to include the data of the testimoniesYesNo

Name and surnames*

Telephone

E-mail*

I would like to include another testimonyYesNo

Name and surnames*

Telephone

E-mail*

Description of the accident or incident

Place of occurrence*

Please indicate if you were telecommuting*YesNo

Date*

Hours*

Please include as many details as possible*
Give as many details as possible (sequence of events over time that may have led to the accident or incident, description of the activity you were performing, equipment or materials you were using, chemical, physical or biological agents that were handled or present in the work environment, whether you were at your usual workplace or at another company/institution/field trip, etc.)

Damage suffered
(please mention the medical care you received)

Material damage

Explanations or observations

Proposed measures to be taken to avoid future accidents

Photos of the accident
Images .jpg or .png, maximum 3Mb

Signature

Signature of the person communicating the accident
(Draw your signature)

Right of information in relation to the data processing
(1) The responsible for the processing of your data is the Secretary General of the University of Barcelona. (2) The purpose of the treatment is to manage the prevention of occupational risks. (3) You have the right to access your data, rectify them, delete them, oppose their processing, request portability and the limitation of processing, in certain circumstances. (4) You can consult detailed information on the above-mentioned treatments

I declare that I have read the information right