Accident / Near Miss Reporting Form

Accident / Near Miss Reporting Form

Please try to avoid using the auto fill function on this form. The purpose of this form is to inform Lead Volunteers and Appropate Trustees of accidents and near misses in the county. This form is used to collect personal data about you and the individual affected. We take the obligation for personal data privacy seriously. The data you provide to us is handled and retained in accordance with our data protection policy. For further details on how we manage personal data, please visit our Data Protection Policy: https://www.scoutshw.org.uk/about-us/data-protection
Is this...*

Accident or InjuryNear miss
Your District*
Your Group
Note- they are grouped by alphbetically by District
Injured Person / Affected Person*
Age*
Date of Incident*

DayMonthYear
Date
Time of Incident*

Hour Minutes

AM/PM Option
Was this
Location*
What was the activity being undertaken and brief description of the accident or near miss:*
Details of injury and medical Treatment received.(If Appropaite):
If first aid was provided, name of the person:
Person completing the form*
Your Email*
example@example.com
Please check if this incident needs to be reported to HQ on the online Incident Reporting form and retain a copy for your records.
District and Group*
If not in County , please state which group and/ or organisation
Should be Empty: