Full Name (the person completing the form)
Role (the person completing the form)
Club/Society/Dept
Date
Please complete the details below:
Consent was given from the injured party to record their personal information: YES: NO:
If consent was not given, was the injured party unconscious? YES: NO:
Name of Injuryed Party
Time of Accident
Area Where Accident Occurred Lower FieldDomeSports HallAstroUoC Pitch 1UoC Pitch 2Gym 1Gym 2Oaklands ParkFlorence RoadSherbourne RoadWest Gate PoolInspire Leisureother (please specify below)Please select
Other Venue or specific location
Ambulance Called? YES * NO If yes, Time Called
* Once you have dealt with the incident please ensure you notify the SU Activities Team via email suactivities@chi.ac.uk especially if you have called an ambulance.
Description of the Accident
Details of Injury (Please be specific on type of injury and exact location on body)
First Aid appied
Any Other Action Taken / Relevant Details
When completing this form please try to include as much additional information as you can. Details of surrounding area, contributing factors to the accident and the type of activity being undertaken will all help in ensuring the best possible action is taken.
I understand that when completing this form, my name will be displayed on the email sent, if I am logged in, and that UCSU has a legal responsibility to ensure that all incidents are followed up and investigated, resultantly the name and contact information of the first aider are documented.
Once fully completed please submit the form below: