NLEA Accident/Incident Report Form

NLEA Accident/Incident Report Form

For the purposes of this form, any instance of the word "accident" is meant to encompass accidents, incidents and/or falls, or any other situation requiring submission of this form.
Section One: General Information
Facility Name*
Competition/Event Name*
Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Owner Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Competition Contact Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Section Two: Accident Details
Reporting on*

Accident (event that caused damage, injury or harm, etc.)Incident (near misses, safety or heath event, etc.)Other
Is legal action possible?*

YesMost likelyNoUnlikely
Date and Time of Occurrence*

MonthDayYear
Date
Hour MinutesAM/PM Option
Location of Occurrence *
Where on the property did accident happen? (i.e. outdoor arena, pathway to warm up, in stable)
Did the accident occur ...*
If inside, describe environment
(i.e. lighting, temperature, etc.)
If outside, describe weather conditions
Was the use of alcohol or drugs noticed in any way?*

YesNoUnsureOther
If yes, describe WHICH / HOW / BY WHOM
Were clearly identifiable First Aid personnel on site when the accident occurred?*

YesYes, but hard to identifyNoUnsure
Was an ambulance called?*

YesNoUnsureOther
If person(s) were transported to hospital via ambulance, please indicate which hospital and name of ambulance attendant (if known)*
If ambulance services not used, please enter "n/a".
If person(s) were transported to hospital not by ambulance, please indicate how they were transported*
If not transported to hospital/clinic, please enter "n/a".
Name of injured person(s)
If an injury occurred, state the nature of medical aid/treatment provided and by whom
e.g. First Aid personnel responded, etc.
If an injury occurred, give brief description of the injury
Describe the occurrence in detail*
Please be as specific and thorough as possible. There is no limit to text allowed.
Describe any equipment or materials which may have caused or been involved in the accident, and note any deficiencies in equipment or environment*
Itemize any additional particulars not covered in this submission form that may be of importance or pertinent to the incident*
Estimated total number of people at the competition/event*
Estimated number of witnesses at the competition/event*
Number of people involved in the accident?*
Include all ages. If unknown, enter 0 or estimate.
Number of minors involved in the accident?*
Minors are 18 years of age or younger at the time of submission. If unknown, enter 0 or estimate.

List the following for persons directly involved in this accident*

	Full Name	Adult or Minor?	Contact Information
#1
#2
#3
#4
#5

List the following for any direct witnesses to this accident. Contact information is required as this submission cannot be signed by multiple people. Listed witnesses are strongly encouraged to submit their own report.*

	Full Name	Adult or Minor?	Contact Information
#1
#2
#3
#4

If possible, upload photographs of area, facility, equipment, etc.

Cancelof
Section Three: Submitter Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I consent to be contacted for additional questions and/or follow-up regarding the accident/incident.*

YesNo
I hereby declare that the above reported information, to the best of my knowledge, is true and complete.
Signature*

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Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

NLEA Accident/Incident Report Form

Section One: General Information

Section Two: Accident Details

Section Three: Submitter Information