ACCIDENT/INCIDENT REPORT FORM

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

Site/Venue where the accident/incident took place:………………………………………………………………………………..

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

Name of Injured Person: …………………………………………….

Address: ………………………………………………………………………………………………………………………………………

Post Code: …………….

Tel: ……………………………………………….

Give details of how and precisely where the accident/incident took place. Describe what activity was taking place e.g. training, match, getting changed etc. ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Result:

• Was first aid administered?

No ……………….

Yes ………………                          By whom? ……………………………..

Treatment: ……………………………………………………………………………………………………………..

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

• Were any of the following people contacted?

Police:                                                            Yes                                         No

Ambulance:                                                   Yes                                         No

Parent/carer/guardian:                                Yes                                         No

• What happened to the injured person following the accident/incident? E.g. went home, went to hospital, carried on with session etc……

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

All the above facts are a true record of the above accident/incident

Signed ………………………… Print Name………………………………   Date ……………..

Copy to Club Welfare Officer……  Yes/No

In the event of an accident/incident occurring through insufficient training or faulty equipment/facilities, the follow up action taken should include the completion of a Risk Assessment.