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Horsley u3a Incident Report Form

This form should be completed by a member of the committee or a group leader. When completing the form, do not admit fault or liability. On completion and after submitting the form it will be automatically sent to the Horsley u3a Group Support Team. The completed incident form should be retained on file by the u3a committee for a minimum of three years, regardless of whether a claim appears likely.

1. Your Details

Name*

Position*

Email*

Telephone*

Address*

2. Incident Details

Date of Incident*

Time of Incident*

Where did the incident occur*

Please state the reason for the injured person or damaged property being there*

Please describe the circumstances of the incident.*

500 characters left

Sections 3 and 4 are to be completed for any incident involving injury

3. Particulars of the injured person(s)

Name*

Email*

Phone*

Address*

Were they a member of your u3a on the date of the incident?*

YesNo

Were they wearing suitable footwear? If relevant to the incident.*

YesNo

Please add any comments made at the scene by them*

4. Details of injury

Describe the injuries*

500 characters left

What immediate action was taken?*

500 characters left

What treatment was given at the scene?*

500 characters left

Were they admitted to or treated in hospital? Please give details*

500 characters left

Are they receiving ongoing medical treatment? Please give details*

500 characters left

Section 5 to be completed for any incident involving damage to property

5. Details of damaged property

Describe damage caused

500 characters left

Estimated cost of repair or replacement

Name of owner of damaged property

Phone

Address

The remaining sections are to be completed for all incidents

6. Name, contact details and comments of witness(es) to the incident

Name*

email*

Phone*

Address*

Comments made*

500 characters left

7. Other environmental conditions (weather, dry, rain etc) or (flooring, liquid present, cleaned away)

Other environmental conditions*

500 characters left

Declaration

Your Name*

I declare that to the best of my knowledge and belief, all of the details provided are true and correct in all respects*

Signed*

Date*