Accident Report Form
Your name
*
Position held
*
Email address
*
This is used to sign this form electronically
Did the accident occur on-site at Rossall?
Yes
No
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Who was injured?
Type of person
Student
Employee
Agency staff
Contractor
Visitor
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Details of the injured student
Student's Name
*
Year group
*
Baby room
Rainbow
Pre-School
Reception
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
Year 7
Year 8
Year 9
Year 10
Year 11
Year 12
Year 13
House
*
Enter house or n/a(not applicable)
Days absent
Absent
*
Yes - accident resulted in absence
No
Not known
House parent informed?
No
Yes
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Details of the injured employee
Employee's Name
*
Job title
*
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Details of the injured agency person
Agency Staff Name
*
Agency
*
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Details of the injured contractor
Contractor's Name
*
Company
*
Contact details
Rossall contact
*
The person who requested the work to be done
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Details of the injured visitor
Visitor's Name
*
Address
Postcode
Other contact details
Provide details such as if it's ok to contact, mobile number,<br> best time to contact etc.
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Incident details
Accident location
*
Date & time of accident
*
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Year
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Hour
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Minutes
Indicate the injuries sustained by marking the position on the body
Injury sustained
*
Bruise
Burn
Cut
Fracture
Scald
Sprain
Strain
No injury
Other
Type of accident
*
Slip
Trip
Handling
Hit by object
Mechanical
Chemical
Other
First aid required?
First Aid
Hospital
Own Doctor
Refused treatment
Rossall Medical Centre
None
Other
First aid required?
*
No
Yes
Hospital
Details of first aid/hospital treatment required
*
Was ambulance called?
*
Yes
No
Did injured person return back to work?
*
Yes
No
If no please comment
Witness details
Provide names and contact details of any relevant witnesses
Description of incident
*
Ensure you provide details of the activity being undertaken at the time of the accident
Submit
Should be Empty: