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Accident or near miss
This form is to be completed by Community Resilience North Somerset Volunteers as soon as possible after an accident or near miss in the course of their volunteer activity.
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Is this an:
Accident/Incident
Near Miss
Clear selection
Date of Accident/Incident?
MM
/
DD
/
YYYY
Time of Accident/Incident if known?
Time
:
AM
PM
Where did the Accident/Incident happen?
Your answer
Name of persons involved in the Accident/Incident?
Your answer
Name of person reporting the Accident/Incident?
Your answer
Names of any persons witnessing Accident/Incident?
Your answer
Full account of the Accident/Incident - including what was in your view responsible for the incident
Your answer
Was any person injured?
Yes
No
Who was injured and what injuries did they sustain?
Your answer
Have any measures been taken or planned to prevent this incident happening in the future?
Your answer
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