Incident Report Form
This form is to be used any student activity group (sports club, society, volunteering project etc) to record an accident, incident, dangerous occurrence or near miss. It must be completed as soon as possible after the incident and you must contact JMSU at the earliest opportunity (up to 24hrs after it takes place).

Depending on the type of accident/near miss this report may just be kept on file with no further action required. However someone from the Student Union may be in touch to discuss further.
Sign in to Google to save your progress. Learn more
Student Group Name e.g. Yoga *
Team e.g. 1st Football Team
Injured/Affected Person:
Full Contact Name of Person Involved *
Date of Birth *
MM
/
DD
/
YYYY
Student Address *
Main Contact Number *
Main Contact Number *
Incident/Accident Details
Incident/Accident Date *
MM
/
DD
/
YYYY
Incident/Accident Time *
Time
:
Location of Incident/Accident *
Description of Accident/Incident *
Please state any injuries *
First Aider Name *
Description of Action Taken *
Detail of any witness(es) and contact information *
Details of Person Completing the Form
Name *
Position in the Group *
Student Email Address *
By submitting this form, you consent to us contacting you further with regards to the information provided. We will not share your contact details with any third parties or contact you with regards to any other activities. If you require any further information as to how we will store your contact information, please write to JMSUDPO@ljmu.ac.uk. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms