"Accident Report Form - Mgtraining"

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PART A
Number
Name
Date
PART B
Person Affected
Name
Complete this section, as fully as
possible, with the details of the
Address
person affected by the incident,
accident or occurrence.
‘Occupation’ may be ‘Child’ or
‘Pupil’ in the case of a school or
Postcode
Date of Birth
early years setting. ‘Client’ in the
case of the care sector
Occupation
Accident / Incident / Occurrence
Date
Time
Where did the accident, incident
or occurrence happen?
Place
Be as specific as possible.
Description
What happened during the
accident, incident or occurrence?
Injury
If someone was injured …
What exactly was the injury?
Include ‘left’ / ‘right’ descriptions.
Be as specific as possible
Action
What did you do as a result of the
accident/incident/occurrence?
What first aid was given?
Were they hospitalised or advised
to go to their doctor?
Person Reporting
Name
Complete this section, as fully as
possible, with the details of the
Address
person who is reporting the
incident, accident or occurrence.
This is normally the person
Postcode
completing the form.
Occupation
Sign and Date it.
Signed
Date
Parent / Carer Signature
Name
Relationship
If the person affected is a child.
Ask the parent or carer to sign
Signed
Date
after explaining the incident.
PART C
Summary for Casualty / Parent / Carer
Name
Summarise here the details of the
accident, incident or occurrence
Date
Time
from the information above and
allow the parent or carer to take
Place
this section away with them for
reference. Tick if a head injury.
Description
If this box is ticked …
The casualty has suffered a
Injury
blow to the head and may be
suffering from concussion.
Please read the guidance
Action
notes given overleaf
© MGTraining, 12 Church Lane, Little Bytham, Grantham, NG33 4QP
01780 411015
www.mgtraining.co.uk
This form maybe reproduced freely by clients of MGTraining with our permission
PART A
Number
Name
Date
PART B
Person Affected
Name
Complete this section, as fully as
possible, with the details of the
Address
person affected by the incident,
accident or occurrence.
‘Occupation’ may be ‘Child’ or
‘Pupil’ in the case of a school or
Postcode
Date of Birth
early years setting. ‘Client’ in the
case of the care sector
Occupation
Accident / Incident / Occurrence
Date
Time
Where did the accident, incident
or occurrence happen?
Place
Be as specific as possible.
Description
What happened during the
accident, incident or occurrence?
Injury
If someone was injured …
What exactly was the injury?
Include ‘left’ / ‘right’ descriptions.
Be as specific as possible
Action
What did you do as a result of the
accident/incident/occurrence?
What first aid was given?
Were they hospitalised or advised
to go to their doctor?
Person Reporting
Name
Complete this section, as fully as
possible, with the details of the
Address
person who is reporting the
incident, accident or occurrence.
This is normally the person
Postcode
completing the form.
Occupation
Sign and Date it.
Signed
Date
Parent / Carer Signature
Name
Relationship
If the person affected is a child.
Ask the parent or carer to sign
Signed
Date
after explaining the incident.
PART C
Summary for Casualty / Parent / Carer
Name
Summarise here the details of the
accident, incident or occurrence
Date
Time
from the information above and
allow the parent or carer to take
Place
this section away with them for
reference. Tick if a head injury.
Description
If this box is ticked …
The casualty has suffered a
Injury
blow to the head and may be
suffering from concussion.
Please read the guidance
Action
notes given overleaf
© MGTraining, 12 Church Lane, Little Bytham, Grantham, NG33 4QP
01780 411015
www.mgtraining.co.uk
This form maybe reproduced freely by clients of MGTraining with our permission
Advice for Head Injuries
If the person affected by the accident, incident or occurrence has experienced a head injury then the person looking after
them should be alert to the following circumstances which may suggest a head injury requiring further assistance …
a bad headache which gets worse or doesn’t go away within 4 to 6 hours of the accident or incident.
drowsiness, if it lasts for more than 2 hours, or if the person is difficult to wake up.
confusion and disorientation.
feeling sick or vomiting. This is common after head injuries but should not be persistent or get worse.
If any of the above are present then you are advised to …
… seek assistance from your doctor
or if you can’t contact your doctor, go to the nearest hospital accident and emergency department
or in severe cases, call 999 and ask for an ambulance
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