Student Group Incident and Accident Report

Please complete after any incident or near-miss, for any student group related activity.
The Form should be completed within 24hours of any incident.

Society/Club Name *
Date of Incident Date of Incident * / DD / MM YYYY
Venue *
Please give student's name Please give student's name * First Last
Are they a current UCLan student? *

Are they a current UCLan student? Yes No
Please indicate if this was one of the following *

Please indicate if this was one of the following Incident Accident Near Miss
Please describe how the accident/ incident/near-miss happened *
Who treated the injury? Who treated the injury? * First Last
Occupation/Course *
Are they first aid trained *

Are they first aid trained Yes No
Was there a coach or instructor present? *
What actions were taken? *
Was an ambulance called? *

Was an ambulance called? Yes No
Was there any further advice given to the injured individual? *
Were there any witnesses? If so, please provide names including First Aider as applicable:
Committee member - I confirm that all information in this report is submitted to the best of my knowledge

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Committee Member Committee Member * First Last
Email *