Group details
Name of group_________________________________________________________________________
Name of group leader___________________________________________________________________
Names of others present_________________________________________________________________
Accident details
Date and time of accident/incident_________________________________________________________
Name of person involved_________________________________________________________________
Date of birth of person involved___________________________________________________________
Emergency contact details for the person involved (usually parent/guardian)
Name________________________________________________________________________________
Telephone number______________________________________________________________________
Please describe the accident/incident that occurred (continue on separate sheet if necessary).
_____________________________________________________________________________________
_____________________________________________________________________________________
Action taken during and following the accident incident.
_____________________________________________________________________________________
_____________________________________________________________________________________
People contacted (include dates and times)
If medical attention was required, please note the name and address of the medical facility and the people who treated the person involved in the accident/incident.
_____________________________________________________________________________________
_____________________________________________________________________________________
Please detail any follow-up action required.
_____________________________________________________________________________________
_____________________________________________________________________________________
Name of person completing this form (print name)____________________________________________
Signed__________________________________________ Date________________________