ARUN EAST
Affiliated to the Third Age Trust
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Incident Report Form
Arun East u3a Incident Report Form
Please note that this form must be completed by a group leader, committee member, orthe property owner. It will be retained on file by the Arun East u3a Secretary for up to tenyears, even if a claim appears unlikely.
1. Your Details
Name
*
First
Last
Phone
Email
Address
Street Address
Street Address Line 2
Town
Postcode
2. Incident Details:
Date of Incident:
Time of Incident:
Where did the Incident occur?
Please state the reason for the injured person or damaged property being there
Please describe the circumstances of the incident
Upload a file(s) if necessary (max 2MB)
3. Particulars
Name 1
First
Last
Address
Street Address
Street Address Line 2
Town
Postcode
Phone
Email
Was he/she a member of your u3a on the date of the incident?
Yes
No
Name 2
First
Last
Address
Street Address
Street Address Line 2
Town
Postcode
Phone
Email
Was he/she a member of your u3a on the date of the incident?
Yes
No
Sections 4 and 5 are to be completed for any incident involving injury.
4. Particulars of the injured person(s)
Name 1
First
Last
Address
Street Address
Street Address Line 2
Town
Postcode
Phone
Email
Was he/she a member of your u3a on the date of the incident?
Yes
No
Name 2
First
Last
Address
Street Address
Street Address Line 2
Town
Postcode
Was he/she a member of your u3a on the date of the incident?
Yes
No
Details of Injury
Describe the injury/injuries
Immediate action taken
Treatment at the scene
Admission to hospital
Ongoing medical treatment
Section 6 is to be completed for any incident involving damage to property.
6. Details of damaged property
Describe damage caused
Estimated cost of repair or replacement
Name of owner of damaged property
First
Last
Address
Street Address
Street Address Line 2
Town
Postcode
Phone
Email
The remaining sections are to be completed for all incidents.
7. Name and contact details of any witnesses to the incident
Space for witnesses
8. DECLARATION
*
I/We declare that to the best of my/our knowledge and belief all the foregoing particulars are true and correct in all respects
Submit
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