Accident Or Serious Incident Report Form printable pdf download

Accident Or Serious Incident Report Form

Accident or Serious Incident Report Form

Team (Age, Gender, Team Name): _________________________________________________________

1. Site where accident took place: __________________________________________________________

2. Name of person in charge of session/competition: ___________________________________________

3. Name of injured person: ________________________________________________________________

4. Address of injured person: ______________________________________________________________

5. Date and time of incident/accident: _______________________________________________________

6. Nature of incident/accident: _____________________________________________________________

_______________________________________________________________________________________

7. Give details of how and precisely where the accident/incident took place. Describe what activity was

taking place e.g. training programme, getting changed etc.

_______________________________________________________________________________________

8. Give full details of the action taken including any first aid treatment and the name(s) of the first

aider(s)

_______________________________________________________________________________________

9. Were any of the following contacted?

Ambulance

Yes

Parent / Guardian

Yes

10. What happened to the injured person following the accident/incident?

(E.g. went home, went to hospital, carried on with session)

_______________________________________________________________________________________

11. Declaration: All of the facts are a true and accurate record of the incident/accident.

Signed ___________________________Print Name ______________________________________

Position __________________________ Date ___________________________________________

Accident Or Serious Incident Report Form