|
Name |
Forename and Surname |
|
Age |
Self explanatory |
|
Gender |
'Male' or 'Female' |
|
Home/College Address |
Self explanatory |
|
Postcode |
Self explanatory |
|
Telephone |
State your most used telephone number whether this be
a landline or mobile number. Please include the area code. |
|
Job Title |
Student or Staff member or for the non-student the
actual occupation of the injured person. |
|
Department/Club |
Name of person's club |
|
Supervisor/Trip Leader |
Name of person in charge of the Club |
|
Time and Date of Accident |
Date of accident |
|
Where did the accident happen? |
If at home 'Wellsway pitch', or if away, state the
location as accurately as you can record. |
|
How was the injured person treated? |
'First Aid' or 'Hospital' or 'Other'
If First Aid then factually list what was carried
out. |
|
If Hospital treatment was needed, did the injured
person remain there for more than 24 hours? ‘No’ or ‘Yes’ |
Only 'Yes' or 'No'. |
Accident or Incident details
Give a full description of what happened including details of any injury
or damage |
Please include a full explanation covering what, how,
who, where, when etc.. It must be very clear as to how the accident
happened and what took place, including calling the emergency services. |
|
Describe the action to prevent a recurrence of this
type of accident or incident. |
Any advice or information where such an
accident could be prevented would be useful. |
|
Name of person completing this form |
Self explanatory |
|
Date form completed |
Self explanatory |
