Edinburgh Leisure Accident Report Form

1. About the person that had the accident

Is the injured person male or female?

Date of birth

Was it a member of staff or public

Job title:

Payroll number:

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

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
Facility where it happened

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.
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?

4. Details and signatures

Were there witnesses?

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:

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):

Additional comments:

5. Investigation

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

Investigation comments

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

Investigation photographs.
Name and signature of person completing investigation

Comments

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.