SIF 10/05
Accident/Incident Report Form This form should be completed by the Group Leader, or County Commissioner, in the case of a county activity. It should NOT be completed by or referred to the injured person or any person acting on his/her behalf. The form should be returned to National Office in Larch Hill within 7 days. If all information in not to hand, please return the form immediately and forward this information later. All information appearing on this form is strictly confidential.
Group Name Section
Names of main witnesses to incident
Injured person (full name Mr/Mrs/Ms etc.) ______________________________________________________ Address
Additional witnesses can be listed on back of form
Phone numbers Date of Birth
Occupation
Who was in charge? Position
Yes ☐ No ☐ Is the injured person a member of the Association If no, was the injured person helping to run the activity Yes ☐ No ☐
Date and time of incident
Type of activity
Location of incident (full address)
To whom was incident reported
Phone Numbers (H) Date reported Did the injured person: Go Home ☐ Visit Doctor ☐
(M) Time reported
Go to A&E ☐
Stay In Hospital ☐
Name of Doctor / Hospital What treatment was given:
Page 1 of 3 Please note this form should only be shared with National Office and Insurance, if a Parent / Guardian requires a copy they can submit a Subject Access Request through Scouting Irelands Data Protection Officer.