Incident Report

This report must be completed when any accident or incident involving a person has occurred in relation to any Southern FM activity, on rented premises or at another location whether or not an injury or illness is apparent as a result. This can be prepared by the person involved or another person who knows the facts (such as witness to the event) and should be completed as soon as possible after the incident. This will provide Southern FM with a record of the incident in case of any future claim.

Date of accident/incident *

Time of accident/incident *

First name of person involved *

Last name of person involved *

Phone/mobile (if known)

Role of member at time of accident/incident *

Location of accident/incident *

Describe the nature of the accident/incident *

Describe any injury/illness caused by the accident/incident

What assistance was provided? (First aid, medical, other)

Was an ambulance required? *
YesNo

Witness information

Witness first name (If applicable)

Witness last name (If applicable)

Witness phone/mobile (If applicable)

Witness email address (If applicable)

Suggested follow-up action

Person reporting the accident/incident

First name *

Last name *

Phone/mobile number (Optional)

Email address *

Date of report *

* Denotes required fields