Fill and Sign the Title Iv Authorization Form 2012 13 1doc Nwhealth

File Ref …………….. Notification of Accident Coach/Member/Visitor All questions must be answered (Please delete whichever is inappropriate) (Complete the appropriate section including C) To ____________________________________ From __________________________________ Date ________________________ A Complete for Accident to Coaching Staff (including temporary or casual staff) Name of injured person _____________________________________________________________________ Job Title ___________________________________________________________________________________ Date of Accident ______________________ Time of Accident ______________________________ Date Reported ________________________ Time Reported ________________________________ B Complete for Member/Visitor(Delete appropriate) Name of injured person ____________________________________________________________________ Home Address ____________________________________________________________________________ Reason for visit to Clydesdale Cricket Club ___________________________________________________ Date of Accident ______________________ Time of Accident ______________________________ Date Reported ________________________ Time Reported ________________________________ Accident Report Form Clydesdale Cricket Club – Junior Section Page 1 of 5 C Complete for all Accidents (Where not applicable,please indicate) Nature and extent of injuries where known (state left or right where applicable) How did accident happen? (Full description of incident) Accident Report Form Clydesdale Cricket Club – Junior Section Page 2 of 5 C (Continued) Where did the accident occur? (Precise Location) 1.1 WAS ACCIDENT DUE TO LIFTING BY HAND? YES NO IF YES Total estimated weight of load lifted ________________________________________________________ How many other persons assisted with the lifting? ___________________________________________ 1.2 WAS ACCIDENT CAUSED BY MACHINERY? YES NO IF YES The name and type of machine ___________________________________________________________ Part causing injury ______________________________________________________________________ Whether in motion by mechanical power at the time? _______________________________________ 1.3 WAS ACCIDENT RELATIVE TO A FALL OF PERSONS, MATERIAL, PLANT ETC? YES NO IF YES What material? _________________________________________________________ 1.4 WAS ACCIDENT CAUSED BY FAULTY PLANT/EQUIPMENT? YES NO IF YES What plant/equipment failed? _____________________________________________________________ How plant/equipment failed? _____________________________________________________________ Accident Report Form Clydesdale Cricket Club – Junior Section Page 3 of 5 1.5 WAS ACCIDENT CAUSED BY FAULT OF ANY PERSON? YES NO IF YES Name, if known ________________________________________________________________ Nature of fault ________________________________________________________________ What exactly was the injured person doing at the time of the accident? ______________ ______________________________________________________________________________ Was he/she authorised or permitted to do this ? Yes No Was this a written down procedure? Yes No If not, was this custom and practice? Yes No Were general or specific instructions given prior to commencement?Yes No If so, state what instructions and by whom given ______________________________________________ 1.6 WAS PROTECTIVE CLOTHING OR EQUIPMNT NECESSARY FOR THE ACTIVITY BEING UNDERTAKEN AT THE TIME OF THE ACCIDENT? YES NO IF YES Give description of such protection __________________________________________________________ Was it provided? Yes No When? __________________________________________________________________________________ Was it being used at the time of the accident? Yes No If no, why? ______________________________________________________________________________ Has the accident been entered in the Club Accident Book? Accident Report Form Clydesdale Cricket Club – Junior Section Page 4 of 5 Yes No 1.7 DID INJURED PERSON REPORT TO A FIRST AIDER POST? YES NO IF YES At what time _____________________________________________________________________________ Accompanied by anyone? Yes No If Yes, who? ____________________________________________________________________________ State name(s)of witness(s) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Have You Obtained a statement from each witness? Yes No Drawn a sketch or taken a photograph showing location and people? Yes No Kept the offending tool/implement? Yes No If Yes, please attach If Yes, what has been kept and where? _____________________________________________________________ ____________________________________________________________ Signatures Date _________________________________ Person Completing Form ________________________________________________________________________ Junior Convenor _______________________________________________________________________________ Please do not delay completing and sending this form and follow up with photographs,sketches and statements as necessary. Accident Report Form Clydesdale Cricket Club – Junior Section Page 5 of 5