PERSON AFFECTED:

WHERE & WHEN THE ACCIDENT /  INCIDENT / NEAR-MISS OCCURRED:

First Name:

Surname:

Location: (i.e. Venue, Court Number?)

THE ACCIDENT / INCIDENT / NEAR-MISS:

(Give a brief description of what happened)

Date:

Time:

Was an Ambulance Required

YES

NO

From which Hospital

Was the injured person taken to hospital

YES

NO

Name of venue staff person to whom incident reported

Date reported to venue staff

Time reported to venue staff

Details of treatment injured person received

WITNESSES (try to get name, address and contact number for at least two)

Name of first aider who dealt with incident

Club

PERSON COMPLETING THIS FORM:

Name: (Please Print)

Signature

Club

Contact Telephone Number

Date form completed

COMPLETED FORMS TO BE SENT WITHIN SEVEN (7) DAYS OF THE INCIDENT TO

Mrs Helen Lewis, Correspondence Secretary, Andover & District Netball Association

Email: correspondence@andovernetball.co.uk