STEVENAGE U3A Charity Number 801069

Incident report form

This form should be completed by a member of the committee or by a group leader. The completed incident form should be retained on file by the u3a committee for a minimum of three years, regardless of whether a claim appears likely.

Any incident in which a member has been injured, or property has been damaged, must be reported to the Third Age Trust via email to info@u3a.org.uk. All incidents are reported to the insurers, regardless of whether there is a claim or not.

1.  Your details

u3a
Name
Position
Email
Telephone
Address
Postcode

2.  Incident details

Date of incident
Time of incident
Where did the incident occur?
Is there any CCTV footage of the incident?	Yes          No
Please state the reason for the injured person or damaged property being there
Please describe the circumstances of the incident Attach a sketch or photograph(s) if possible

3.  Particulars of person(s) involved in the incident

(continue on a blank page if necessary)

Name
Email
Telephone
Address
Postcode
Were they a member of your u3a on the date of the incident?		Yes          No

4. Type of incident

What type of incident are you reporting?
Injury	Skip section 7
Damage to property	Skip sections 5 and 6
Both – injury and damage to property	Please complete all sections

5.  Particulars of the injured person(s)

Please make sure you have listed them in section 3

Name
Were they a member of your u3a on the date of the incident?	Yes          No
Please add any comments made at the scene by them
Were they wearing suitable footwear? (if relevant to the incident)	Yes          No

6.  Details of injury

Describe the injuries

What immediate action was taken?

What treatment was given at the scene?

Were they admitted to or treated in hospital? Please give details

Are they receiving ongoing medical treatment? Please give details

7.  Details of damaged property

Skip this section if not reporting damage to property

Please describe the damage caused (to be completed by a committee member or Group Leader)
Estimated cost of repair or replacement
Name of owner (of damaged property)
Address
Postcode
Email
Telephone

The remaining sections are to be completed for all incidents

8.  Name and comments of witnesses to the incident

(Continue on a blank page, if necessary)

Name
Comments made

Name
Comments made

9. Other environmental conditions (weather, dry, rain etc) or (flooring, liquid present, cleaned away)

10. Declaration

Your name
I declare that, to the best of my knowledge and belief, all of the details provided are true and correct in all respects.
Date
Signed

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