Accident Reporting Form – 2nd Acomb Scout Group

Leader's Name *

First

Last

Name of leader reporting the accident

Leader's Email Address *

Enter your 2nd Acomb Scouts email address

About the Casualty

Please complete the following fields, a separate form will be required for each casualty

Name *

First

Last

Please enter the name of the casualty

Date of Birth *

Please enter the date of birth of the casualty

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Please enter the address of the casualty

Role

Role of the injured party

Age Group *

Please indicate if the casualty is a child or an adult

Section *

Casualties Section

Main Contact *

Name of the main contact for the injured party, e.g. parents name

Main Contact's Phone Number *

Phone number of the above named main contact

Main Contact's Email Address *

Email address of the above named main contact

Phone Number *

Phone number of the injured party

Email *

Email address of the injured party

About the Incident

Please enter full details of what happened in the fields below

When *

Date

Time

When did the incident occur?

Where *

Please enter the location that the accident happened

What happened? *

Please describe the incident, what happened?

Nature and location of any injuries *

Please describe the type of injury and where is on the body as specifically as possible

Treatment given: *

Please list in as much detail as possible the treatment that was given and by whom it was administered

Witness Details: *

Please list the name and email address/ phone number of anyone who witnessed the incident

After the accident the person involved *

Continued with the meeting/ event
Went home early
Went home as it was the end of the meeting/ activity
Went to Hospital
Went to their GP
Went to their Dentist
Went to another medical practitioner (please specify more details below)

More details *

Did the accident involve a bump to the head? *

Was anyone contacted during the session? *

This form gets emailed to the parents email address on OSM and to the GSLV once completed.

Who was contacted? *

First Aid Equipment Used *

Please list any items from the first aid kit which were used and need to be replaced. Enter none if no first aid supplies were used.