Reporting an Incident

An accident or incident has occured or nearly occured.

This form should be completed by ---- and will be automatically sent to the Health and Safety Representative.

Accident/ Incident/ Near Miss Report

Date of Accident/Incident

Time of accident/Incident

Time

HoursMinutes

Location & Conditions

Activity Taking Place

What Happened

Witnesses

Injury Details

First aid administered and who by

Advice given to injuredparty/guardians

Were GP/Emergency Services called?

Yes

Outcome

Results of Follow-up Call

Name of person in charge

Number of children present?

Additional Notes

Injured Person

First name

Last name

Date of Birth

Gender

Male

Female

Name of Guardian

Phone

Report Recorded By

Name

Tel:

A copy of your report will be sent to this email address for your own records.

I confirm that the information above is a true and accurate record of the incident/accident or near miss occurrence.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.