ANDOVER & DISTRICT NETBALL ASSOCIATION
ACCIDENT, INCIDENT OR NEAR-MISS REPORT FORM
(Please complete ALL sections)
PERSON AFFECTED: | WHERE & WHEN THE ACCIDENT / INCIDENT / NEAR-MISS OCCURRED: | ||||||
First Name: | Surname: | Location: (i.e. Venue, Court Number?) | |||||
THE ACCIDENT / INCIDENT / NEAR-MISS: (Give a brief description of what happened) | Date: | Time: | |||||
Was an Ambulance Required | YES | NO | |||||
From which Hospital | |||||||
Was the injured person taken to hospital | YES | NO | |||||
Name of venue staff person to whom incident reported | |||||||
Date reported to venue staff | Time reported to venue staff | ||||||
Details of treatment injured person received | WITNESSES (try to get name, address and contact number for at least two) | ||||||
Name of first aider who dealt with incident | Club | ||||||
PERSON COMPLETING THIS FORM: | |||||||
Name: (Please Print) | Signature | Club | Contact Telephone Number | ||||
Date form completed | COMPLETED FORMS TO BE SENT WITHIN SEVEN (7) DAYS OF THE INCIDENT TO | ||||||
Mrs Helen Lewis, Correspondence Secretary, Andover & District Netball Association Email: correspondence@andovernetball.co.uk |