Health & Safety - Accident Reporting Form

Section 1 - Accident Details

Please state what happened: *

Date of Accident: *

Time of Accident: *

Site of Accident: *

Athletics Activity Type: *
Long Jump Hammer High Jump Triple Jump Discus Javelin Shot Pole Vault Sprint Hurdles 400m Hurdles Steeplechase Sprints Track Endurance activity Wheelchair event Seated Throw Fell/Trail Running Road Running Physical Preparation Training Warm up Activity Cross Country Running Other - Please state

Please select the Athletics Event

Category: *
Property Damage Slip / Trip / Fall Sporting Injury Struck by Object Other (please state)

Please choose.

Body Part Injured: *
Mouth Buttocks Foot Trunk - Disc No Physical Injury Chest Upper Arm Lower Leg Hip Multiple Trunk Toe(s) Vertebrae Internal Organs Wrist(s) and Hand(s) Eye(s) Abdomen including Groin Wrist Multiple Lower Extremities Neck - Multiple Injury Multiple Head Injury Thumb Skull Insufficient Info to Properly Identify - Unclassified Upper Back Area (Thoracic) Lumbar and/or Sacral Vertebrae Body Systems and Multiple Body Systems Disc Hand Lower Arm Shoulder Upper Leg Ankle Arm Knee Whole Body

Please select the most appropriate body part injured

Type Of Injury: *
Burn Dislocation Inflamation Loss of Hearing Dizzy/Faint Mental Disorder Foreign Body Strain Electric Shock No Physical Injury Rupture Fracture Laceration Crushing Multiple Injuries Including Both Physical and Psychological Freezing Asphyxiation Hernia Sprain Chest Pain Stroke Carpal Tunnel Syndrome Bruise Graze unknown Head Injury none Asthma Attack Cardiac Arrest other – please state

Please select the type of injury

Nature of Injury: *

Was First Aid given?: *

Was the injured party taken from site of the accident to hospital?: *

Section 2 - Injured Person Details

Injured Person Name: *

If the details are being reported from a first aid providers casualty card that doesn’t have the Injured Persons Name please state “TBC” and complete as much detail as possible.

Age:
Under 18 Over 18

Injured person's Club:

Contact Address:

Post Code:

Telephone/Mobile Number:

Email Address:

Section 3 - Reporting Person Details

Contact Name: *

Contact Address:

Post Code:

Email Address: *

Phone Number: *

Your Role Status:
Athlete Spectator Official Witness Other

Please select your role.

Section 4 - Venue Details

Meeting Title/Training Venue/Event Name/Club Name: *

Lead Person/Organiser: *

Venue Address: *

Venue Postcode: *

Event: *
Competition Training Other

Please choose if it was in Competition or Training.

Responsible Federation: *
England Northern Ireland Scotland Wales Fell Runners Association

Please select the Federation under which this occurred.

Section 5 - Declaration

I declare that:

• Information provided is accurate.

Your Name: *