Dorcas Befriending Project Incident Form

Dorcas Befriending Project Incident Form

This form must be completed for any health and safety incident experienced by members of the Dorcas Befriending Project which have occurred whilst carrying out the activities of the charity.

It should be used to report all but not limited to first aid incidents; premises related accidents and ill health; acts of violence (physical and verbal abuse and threats to members); and non-injury incidents that had the potential to cause harm (dangerous occurrences or “near misses”).

Please complete the form providing factual and accurate information only, and forward this to the Chair via email to or by post to :

FAO Chair,

The Dorcas Befriending Project,

The Bridge, 80 Arran Walk,

Marquess Estate, Canonbury,

Islington,

N1 2TL.

Serious incidents must be raised within 24 hours by contacting the Chair on 07954100179, and this form must be completed within 48 hours. For all other incidents this form must be completed and sent to the Chair no later than 72 hours following the incident.

The form should ideally be completed by the affected / injured person, their representative or a witness to the incident.

About the Incident
Name of Person Reporting the Incident:
Contact Details:
Incident reported: / Date: / Time:
Type of Incident:
(please indicate) / First Aid / Work related accident / Work related ill health
Work related violence / Non-Injury incident / Other: (please specify)
Date of Incident: / Time of Incident:
Location:
What was being done at the time of the Incident?
What Happened? (please include any contributing factors e.g. bad weather, continue on a separate sheet if necessary)
Nature of Harm / Ill Health / Damage:
Immediate Action Taken:
About the Person Affected
Name: / ID Number:
Address:
Phone Number: / Email
Date of Birth: / Age:
Gender: Male / Female
Role: / Committee Member / Volunteer / Client
Other: (Please Specify)
Signature:
Witness Details
Name(s): / Contact Details:
Post Incident
What Happened to the injured person afterwards?
Went Home / Taken directly to Hospital / Returned to Activity / Work / Other: (Please Specify)
Any Other Information:
Person Reported to:

Data Protection Act 1998: The information provided on this form will be processed in accordance with the Data Protection Act and will only be disclosed within the Dorcas Befriending Project members who need to know. Relevant information will be disclosed outside the Dorcas Befriending Project where it is required by law to do so. In the event of a personal injury claim, information may be disclosed to the Dorcas Befriending Projects Insurers.

The Bridge, 80 Arran Walk,

Marquess Estate,Canonbury,

Islington, London, N1 2TL

020 7704 0605