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Name of person in charge of session
*
Site where incident/accident took place
*
Date and time of incident/accident
*
Day
Month
Month
Year
Time
:
Hours
Minutes
Name of injured person
*
Address of injured person
*
Nature of incident/accident and extent of injury
*
Give details of how and precisely where the incident/accident took place
*
Describe what activity was taking place
*
Give full details of the action taken including any first aid treatment and the name(s) of the first aider(s):
*
Were any of the following contacted
*
Police
Fire Brigade
Ambulance
Family Member
Other
What happened to the injured person following the incident/accident? (eg went home, went to hospital, carried on with session)
*
All of the above facts are a true and accurate record of the incident/accident
Yes
No
Signature of person completing this form
*
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Date and time
Day
Month
Month
Year
Time
:
Hours
Minutes
Submit
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