Accident Record Form

This form is to record any accidents. Please contact us on 020 7709 8900 or admin@halfmoon.org.uk if you have any questions.

About the person who had the accident

Full name(Required)

Are they a participant(Required)

Yes

If yes, what was the event/ group

About you

Full name(Required)

Occupation(Required)

About the accident

Date it occurred(Required)

Time it occurred(Required)

Where did it occur – centre/ school and the room(Required)

Say how the accident happened. Give the cause if you can.(Required)

If the person who had the accident suffered an injury, say what it was.

If you used any first aid equipment, please state what and who's first aid kit it came from

Signature(Required)

The date you are completing this form

By ticking this I give my consent to my employer to disclose my personal information and details of the accident which appear on this from to safety representatives and representatives of employee safety for them to carry out the health and safety functions given to them by law.(Required)

I give consent