Accident Report Form

• Injured persons name:

1. About the person that had the accident

• Is the injured person male or female?

  Male

  Female

• Date of birth

• Was it a member of staff or public

  staff

  public

• Job title:

• Payroll number:

• Was the member of staff off sick due to this incident?

  Yes

  No

• How long were they off for?

• Address

• Telephone number (if under 18 telephone number of parent/guardian):

2. Details of the accident

• When it happened

  Date

• Facility where it happened

  Select Ainslie Park Craiglockhart Leisure and Tennis Centre Dalry Swim Centre Drumbrae Leisure Centre Edinburgh International climbing Arena Glenogle Swim Centre Gracemount Leisure Centre Jack Kane Sports Centre Kirkliston Leisure Centre Leith Victoria Swim Centre Meadowbank Sports Complex Portobello Swim Centre Royal Commonwealth Pool Tumbles at Portobello Warrender Swim Centre

  • Ainslie Park
  • Craiglockhart Leisure and Tennis Centre
  • Dalry Swim Centre
  • Drumbrae Leisure Centre
  • Edinburgh International climbing Arena
  • Glenogle Swim Centre
  • Gracemount Leisure Centre
  • Jack Kane Sports Centre
  • Kirkliston Leisure Centre
  • Leith Victoria Swim Centre
  • Meadowbank Sports Complex
  • Portobello Swim Centre
  • Royal Commonwealth Pool
  • Tumbles at Portobello
  • Warrender Swim Centre

• Where in the facility did it happen?

• Describe what happened giving as much detail as possible:

• Take a photo of the area the incident/accident happened in as soon as possible following the incident.

  Media

3. Injury and first aid.

• Describe the injury (if none state 'none')

• What first aid was applied (if none state 'none')?

• Who was the first aider?

• Was the person taken to hospital?

  Yes

  No

4. Details and signatures

• Were there witnesses?

  Yes

  No

• Name of witness 1

• Address and phone number of witness 1

• Name of witness 2

• Address and phone number of witness 2

• Additional information

• Name and signature of person involved in incident:

  Sign

• In the case of an injury to an under 18 ensure the parents/guardians are contacted if not present, record the name and time of contact.

• Name and Signature of the person completing this report (must be completed when accident is reported):

  Sign

• Additional comments:

5. Investigation

• Could anything have been done to prevent this accident/incident?

  Yes

  No

• Investigation comments

• Detail and follow up actions/things which caused the incident.

• Investigation photographs.

  Media

• Name and signature of person completing investigation

  Sign

• Comments