ENV REC 040

V. 6.0

Report of Environmental Incident/Near-Miss/Nonconformity

Reporting Responsibilities

All environmental incidents, non-conformitiesor near-misses to be reported to SHE Section by completing PART 1 below.

Level 1, 2 or 3 incidents to be reported immediately to Security on Ext: 333

Level / Category / Example description of incident
4 / Local incident / A leakage or spillage of an environmentally hazardous substance that is contained within the local area, has not caused contamination and requires a relatively minor clean upby staff involved(ENVREC049 Spill Containment- Locations and Competent Persons)
3 / Local but significant incidentcontained on site / A leakage or spillage of an environmentally hazardous substance that is contained on site but may require significant clean upby other UCLan staff or a contractor.
2 / Minor Incident - Breach of exemption where the breach does not require United Utilities or Environment Agency to be notified. / An exemption limit has been breached. A list of exemptions that the University has for our operations (water and waste) can be found on the staff intranet
1 / Major Incident - Breach of exemption or legislation (notifiable to Environment Agency or United Utilities) / Leakage or spillage of oil, other hazardous substances or waste that escapes from the site (e.g. into a brook, canal, river, air or uncovered ground).

PART 1

Section to be completed by the witness or Security/SHEon behalf of the witness. Completed forms should be sent to the SHE Section in VE 202 orsent by email to

Details of witness

UCLan Student ☐ Member of staff ☐ Visitor ☐ Contractor ☐

First Name: Click here to enter text.Surname: Click here to enter text.

Job Title (if staff): Click here to enter text.

School/Company/Service/Section: Click here to enter text.

Tel No: Click here to enter text. Email: Click here to enter text.

Any other witnesses? If so, provide names: Click here to enter text.

Incident Details

Date and Time of Incident: Click here to enter text.

Location of Incident: Click here to enter text.

Please provide a short description of incident and include relevant photographs:

Click here to enter text.

  1. Estimated Quantities: Click here to enter text.
  2. Details of Cause (if known): Click here to enter text.
  3. Mitigation measures already taken (if any): Click here to enter text.

Signed: Click here to enter text. Date: Click here to enter text.

PART 2

Section to be completed by SHE staffONLY

Type & Level of Incident

Incident: ☐Near-Miss:☐Non-Conformity: ☐

Level 1:☐Level 2:☐Level 3:☐Level 4: ☐

Root Cause & Incident Handling

What was the root cause of the incident?: Click here to enter text.

What went well and not so well during the handling of it?: Click here to enter text.

Reporting

All incidents will be reported to the line manager or the manager of the area of activity where the incident occurred to discuss actions arising.

Name: Click here to enter text.Email: Click here to enter text.Tel No: Click here to enter text.

Date reported:Click here to enter text.

Action

Explain what action has been agreed to prevent the accident/incident/near miss from happeningagainand attach any e-mail correspondence:Click here to enter text.

Signed:Click here to enter text.Date:Click here to enter text.