Accident Report

Who is reporting the accident:
Your name: Your email:
Your contact number:

General details of the accident:
Date of incident: Time of incident:
Exact location of incident:
Who was in control at the time of the incident (name of Hirer)?:

Person who had the accident (the 'injured person'):
Full name: Age (if under 18):
Address:
Status of the injured person: Hirer of the HallGuest or attendee of the Hirer's eventContractor of the HirerAttendee or guest of the Village HallVolunteer of Village HallCommittee member of Village HallOther
If other, please specify:

Nature of injury (please be as specific as possible and state left or right):

If the injured person was under 18 please provide details of their parent or carer:
Parent or Carer name:
Parent or Carer address:
Parent or Carer contact number:
Parent or Carer notified? YesNoN/A

Description of how accident and/or injury occurred:

Names and addresses of any witnesses to the accident or injury:

First aid treatment given on site?
YesNo
Details of First Aid if applicable:
Did the casualty have to go to Hospital immediately?
YesNo
Details of hospital treatment:
Did the casualty have to go to their GP or hospital as follow up?
YesNoDont know
Details of follow up treatment:
Anticipated absence from work: No time lostLess than 3 days3 days or more
Does the accident need reporting under RIDDOR?YesNoDon't know

Action required to prevent recurrence:

Optionally, please upload photo of injury: