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Safety

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Appendix 18f

The Hong Kong Polytechnic University
Health, Safety and Environment Office

HSE Form 2 (01/2009)
For HSEO Use
Case No.:

香港理工大學
健康安全及環境事務處

Accident/Incident Report Form
意外/事故報告表
Note: This report form should be completed and sent to the Health, Safety and Environment Office in sealed envelop through the Head of Department within 72 hours of the accident/incident. Please refer to Accident/Incident Reporting and Investigation Procedure
(Section A400, Health and Safety Guide). The information provided herein will be used for investigation and compiling accident statistics. In case of work-related accident to employee of the University which results in death or partial incapacity, the concerned department should complete HR Form 67 instead of this form. The HR Form 67 should be filed with the Human Resources Office immediately after such an accident is known and a copy of the form be sent to the Health, Safety and Environment Office.
注意:

此表格須經部門主管於意外/事故發生後七十二小時內批注,以密封函件轉交健康安全及環境事務處。本表格內容只供意外調查及
統計之用。請參考理工大學安全健康指引中A400 號文件:事故及意外之報告及調查程序。
若為僱員因工遭遇意外而致死亡或喪失部份工作能力,有關部門應填寫人力資源處表格HR Form 67,並將副本呈送健康安全及環
境事務處。

1. General Information of Accident: 意外資料
Date 日期:

Time 時間:

Location of
Incident/Accident

Department in charge of the location

事發地點:

事發地點所屬部門:

2. Nature of Incident: 事故性質
i. Personal injury 個人損傷

ii. Damage to property/equipment 財物損失

iii. Spillage of chemicals 化學品洩漏

iv. Fire 火警

v. Incident of significant environmental impact

vi. Others (Please specify)

嚴重環境影響的事故

其他(請詳述之)

3. Personal Data (Complete this section for each injured reporting person): 個人資料(各傷者需個別填寫此格)
Name 姓名:

(
English (Surname first) 英文

)

Sex 性別:

Age 年齡:

Chinese 中文

Dept/Company 部門/公司:

* Student / Staff / Visitor / Contractor
* 學生 / 職員 / 訪客 / 承建商

Contact Telephone:

* Staff / Student No.

聯絡電話

* 職員 / 學生編號

Nature of injury:

* Amputation / burn / contusion / fracture / laceration / sprain/ others (please specify)

受傷性質

* 切斷 / 燒傷 / 撞傷 / 折骨 / 割傷 / 扭傷 / 其他 (請詳述之)

Part of body injured:

* Hand / leg / head / eye / others (please specify)

受傷部位

* 手 / 腳 / 頭 / 眼 / 其他 部位 (請詳述之)

Name of hospital/clinic where injured person received medical treatment:
就醫醫院/診所名稱

University Clinic (UHS)
大學診所

Others

(Date 日期:

)

其他
(to be cont’d 續下頁)
A18f_1

Sick leave recommended:

days

( from

to



建議病假





)

4. Details on how the accident/damage occurred. Sketch on separate sheet, if applicable.
事故發生的詳細內容, 如有需要請附圖例。

5. Causes of accident/incident
事故發生原因

6. Recommendation for prevention of recurrence
建議預防措施

Reported by:
報告者

Endorsed by HoD:
(

)

Date 日期:

部門主管批注

(

Date 日期:

For HSEO Use
Separate investigation report required

No

Yes

* Please delete as appropriate 請刪除不適用
A18g_2

report no.

)

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