NICCA INCIDENT REPORT FORM

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INCIDENT REPORT FORM

Name of person involved in incident: *

Address of person involved in incident (if known): *

Nature of incident and extent of any injuries (if any): *

Give full details of any action taken, including any first aid treatment and the name(s) of the first aider(s): *

Please list all items used from First Aid Equipment (if none - write none) *

Was Defibrillator used *

Yes

Does the First Aid Equipment require replenished *

Yes

Describe what activity was taking place, eg fishing, coaching, maintenance, work party etc. *

Site where incident took place: *

Beechhill Fishery

Conlig Lower Resevoir

Other Location

If "Other Location" please give more details:

Give precise details of where the incident took place:

Were any of the following contacted: *

Ambulance Service

Fire Service

Police

Parent/Guardian/Carer

Partner/Spouse

No one required contacting

Required

What happened to the injured person following the incident? (eg went home, went to hospital, carried on with activity) *

Date of incident. *

Time of incident. *

Time

Were there any witnesses to the incident (If so please list their name (s) and contact details)

Name of person (S) in charge of activity. (if none - write none) *

All of the above facts are a true and accurate record of the incident. SIGNED: *

DATE: *

CLUB POSITION: *

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