SEER Accident/ Incident Report Form - Swim England East Region

This form is only to be completed by the event organiser, promoter, a referee, a member of regional staff, or someone undertaking a similar role at a competition or event hosted by the region only and must be completed as soon as possible at the time of the accident/ incident.

The Regional Manager will be notified of a submitted form, and may be in touch following the event.

SEER Accident/ Incident Report Form

This form is only for reporting accidents and incidents at East Region hosted events. If you are at an open meet or event, please contact ther Promoter/Organiser to complete their accident/incident formwork and ensure that your own club's accident/incident log is also completed.

Name of East Region event

Location where the accident/ incident took place

Date and time of when the accident/ incident occured

Please describe the circumstances of the accident/ incident and what activity was taking place

Please state if any of the following were contacted;

Police Service

Ambulance Service

Fire Brigade

Parent or carer

Team Manager or Coach

None of the above

Other

If you ticked 'other' in the question above please provide more detail

Please list any witness names and contact details

Was anyone injured?

Yes

Name of the injured person

Address of the injured person (or SE membership number)

Club the injured person belongs to

Email address of the injured person

Date of birth of the injured person

Give full details of the action taken, including any First Aid treatment, and the names of the First Aiders

What happened to the injured person after the accident?

Was there a second person injured?

Yes

Name of the 2nd injured person

Address of the 2nd injured person (or SE membership number)

Club the 2nd injured person belongs to

Email address of the 2nd injured person

Date of birth of the 2nd injured person

Give full details of the action taken, including any First Aid treatment, and the names of the First Aiders

What happened to the 2nd injured person after the accident?

Was there a third person injured?

Yes

Name of the 3rd injured person (or SE membership number)

Address of the 3rd injured person (or membership number)

Club the 3rd injured person belongs to

Email address of the 3rd injured person

Date of birth of the 3rd injured person

What happened to the 3rd injured person after the accident?

Give full details of the action taken, including any First Aid treatment, and the names of the First Aiders

Name of the person completing this form

Your role at the event

Membership number of the person completing this form

Email address of person completing the form

By submitting this form I confirm that all of the above facts are a true and accurate record of the accident/ incident. In order to comply with the Data Protection Act 2018, it is essential that all personal details entered onto this accident form are kept confidential and the form is securely stored. This form will be referred to Howdens if required..

I confirm the above facts are true and accurate

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