Incident / Accident Reporting Form

INCIDENT/ACCIDENT REPORTING FORM

Site where accident took place……………………………………………………………….….

Name of person in charge of session/competition ………………………………………..…..

Name of injured person ………………………………………………………………….…...….

Address of injured person …………………………………………………………….…….……

Date and time of incident/accident ……………………………………………………….……..

Nature of accident/incident …………………………………………………………………..….

Give details of how and precisely where the accident took place  ………………………….

………………………………………………………………………………………………..…….

…………………………………………………………………………………………………..….

Describe what activity was taking place, e.g. training etc  ………………………………….

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Give the details of the action taken including any first aid treatment and the names of the first aiders
……………………………………………………………………………………………………...

……………………………………………………………………………………………………...

Were any of the following contacted ?

Police                       YES/NO
Ambulance               YES/NO
Parent/Guardian     YES/NO

What happened to the injured person after the accident?   (e.g. went home, hospital, carried on with session)

………………………………………………………………………………………………….….

I confirm that all of the above facts are a true and accurate record of the incident/accident.

Signed ……………………………………..

Name (Print)  ………………………………

Date  ……………………………………….