Accident & Injury Report Form
For accident reporting only. For concerns of abuse or wellbeing, please use the Concern Form. It is recommended that you also make a member of Exodus staff aware of the accident/injury.
Person Reporting
Your Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Mobile Number
*
Please enter a valid phone number.
Your Local Area
*
Please Select
Banbridge
Belfast
East Antrim
Lisburn
MidUlster
North East (Coleraine)
North West (Derry & Donegal)
Role
*
i.e. Mentor / team leader or coworker / staff member / participant
Back
Next
Person injured/involved in accident
Full Name
*
First Name
Last Name
Gender
*
Male
Female
Age
*
Under 18
18 or over
Unknown
Next of Kin Details (if known)
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Next
Nature Of The Accident/Injury
When was the accident/injury?
*
-
Month
-
Day
Year
Date
Where were you when it occured?
*
eg a drop in in Exodus Lisburn / team 99 team meeting
Describe how the accident/injury occured
*
What aid was given, if any??
*
Who Else was Present (if any)?
*
Who was informed?
*
eg a parents, staff member, emergency services
Any Additional Comments - including further action required
*
To the best of my knowledge the information I've given is accurate
*
Submit
Submit
Should be Empty: