This form must be completed for any injury, dangerous occurrence and near miss in respect of members and visitors.

To be completed by injured person or representative and submitted electronically to the committee.

Section 1

Personal Details

Please tick as appropriate
AccidentDangerous OccurrenceNear Miss

Full Name (required)

Address (required)

Status
MemberVisitor

Section 2

Accident Record

This section concerns details of the injury, dangerous occurrence or near miss. Please be as specific as possible about the type of injury. If a major injury or dangerous occurrence has occurred please contact a committee member as soon as possible.

When did it happen?
Date of occurrence (required)

What happened? (required)

Where did it happen? (required)

How did it happen happen?
Give the cause if you can (required)

Was there an injury?
If so please give details (e.g. fracture, bruise, cut, sprain, strain)

Section 3

Treatment Detail

This section should be completed by a first aider or representative in respect for all treatment whether accepted or refused.

Was First Aid given?
AcceptedRefusedAdvised to attend hospital/GPNot Applicable

Were the emergency services called and in attendance?
YesNo

Description of first aid given

First aiders name (or representative)