Bu3a Incident/Accident/Near Miss Report Form

GDPR Personal Data Compliance Statement:

These personal data are necessary for the purposes for which they are required and will be distributed only as necessary, stored securely, and destroyed after a period of three years.

Section 1: Person Involved in the Incident *

Full Name:

Address:

Section 2: Person Completing This Form *

Full Name:

Email Address:

Phone Number:

Section 3: Details of the Incident *

Name of Group Activity or Event:

Date and Time:

Location (Venue and Room):

How Did It Happen? (Cause, if known):

Section 4: Consequences and Response *

Was Anyone Injured? *

—Please choose an option—YesNo

If yes, give details (or write N/A): *

What Action Was Taken and by Whom? (First Aid/111/999): *

Section 5: Additional Information

Was There Any Damage or Loss to Property?

—Please choose an option—YesNo

If yes, give brief details (or write N/A):

Were There Any Witnesses?

—Please choose an option—YesNo

If yes, provide names, addresses, and contact details (or write N/A):

Section 6: Declaration *

Signature (Name):

Date of Completion:

Section 7: Continuation Sheet

Use this space if additional details are needed: