Accident Report Form
1. Event or Meeting
I.e. Lord's Day Meeting, LIBC, Video Training
2. Hall or Other Venue
Please Select
Hall 1
Hall 2
Hall 3
Hall 4
Hall 5
Hall 6
Other
3. Details of Person Affected/Injured
3.a. Name
*
First Name
Last Name
3.b. Email
example@example.com
3.c. Phone Number
-
Country Code
-
Area Code
Phone Number
3.d. Person Affected Notes
4. Details of Person Reporting this Accident
Is this the same as the person affected or injured in point 3.
Please Select
Yes
No
4.a Name
*
First Name
Last Name
4.b Email
*
example@example.com
4.c Phone Number
-
Country Code
-
Area Code
Phone Number
5. Details of Accident/Injury
5.a. Accident or Near Miss
*
Accident with Injury
Accident
Near Miss
5.b. Date and Time of accident or near miss
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
5.c. Where did the accident or near miss take place?
*
5.d. How did the accident or near miss happen
*
5.e. Describe the nature of the near miss, accident or injury if relevant
*
6. Actions and Recommendations
6.a. Action taken to assist the injured
First Aid
Taken to A&E
Assisted home
Follow up to call later
Next of kin informed
6.b. Action taken or recommendations to prevent future accident, near accidents or injuries
Accident site secured or otherwise made safe
Landlord or venue manager informed
Elder or local responsible brother informed
Other
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The information on this sheet will be treated as private and confidential and will be held in accordance with the General Data Protection Regulation (GDPR) and Data Protection Act 2018. For more information, please see our Privacy Policy at www.churchinlondon.org.uk/privacy or contact office@churchinlondon.org.uk for more information.
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