Section 1

Section 1 - Incident Report (to be completed at the time of the incident)

Please indicate what type of incident you are reporting:

Incident Details
In which facility/site/area did the incident take place?
Which KA Campus?
Which Golf Course?

Which Outdoor Sports Facility?

At which site did the incident occur within a Health & Fitness activity?

At which site did the incident occur within a Sports Development activity?

Where within the site/facility did the incident take place?

Date and Time of the Incident
Injured Person (if applicable)

Full Name

Home Address and Postcode

Telephone Number

Age

Sex:

Status of Injured Person

Is the injured person:

Job Title

Employee Number

What is the name of the contractor's employer?

Full Description of Incident

Please provide as much information as possible:

Witness Details

Were there any witnesses of the incident?

Witness Name

Contact Number

Address and Postcode

Is the witness a KA Leisure Employee?

Were there any other witnesses?

Witness Name

Contact Number

Address and Postcode

Is the witness a KA Leisure employee?

First Aid Treatment

What treatment was administered?

Name of First Aider:

Was the Injured Person advised to attend A&E?

Did the injured person:

For how long was the injured person unconscious?

Injury Details

Nature of Injury (i.e. fracture, burn, cut etc.)

Part of body affected (i.e. head, arm, leg etc.):

Kind of Accident

More detail:

Form Completed By:
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Occupation

Home Address

Section 2

Section 2 - Accident Investigation (to be completed by responsible manager)

Is the incident reportable under RIDDOR?

Reason why N/A?

Accident Investigation

Type of Incident

Responsible manager (preliminary report). H&S Co-ordinator and Leisure Manager (investigation).

Responsible manager (preliminary report). H&S Co-ordinator and Leisure Manager (investigation).

Responsible Manager.

Responsible Manager.

Managers Report

Check the scene, detail any hazards identified which may have contributed to the incident, speak to the first aider and any witnesses where possible. Detail any remedial action taken/required.

Completed By
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Designation

Date
Health & Safety Co-ordinator Report
Date Received

RIDDOR reportable

Further investigation required

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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.