Incident

This form is to be used to capture data and record investigation findings for all accidents and near misses.

Incident Information

What type of Incident?^*

Accident = an event that results in injury, ill health or damage to property. Near miss = an event that, while not causing harm, has the potential to cause injury or ill health.

HSE Injury Kind^*

Date of Event^*

Today's date^*

Time of event^*

Ground Mode^*

Match Day Non Match Day

Event^*

Area^*

Where did this happen?^*

Summary^*

Has this area been made safe^*

Yes No Not Applicable

Is a repair required?^*

Yes No

Personal Details

Person Involved^*

MCC Employee MCC Casual Worker Guest Contractor Middlesex ECB Agency Player Other

If applicable, what department or company do you work for?

Are you completing this form on behalf of the person who was involved in the incident?^*

Yes No

If yes, please provide your Name, Role and Contact Number

Full Name of Injured Person, if applicable

Date of Birth (D.O.B)

Contact Number

Home Address

Postcode

Injury Details

Injury Sustained

Body Part

Was treatment required?^*

Yes No

What treatment was provided?

Where was treatment provided?

Who provided treatment?

Outcome

Please upload any supporting documentation / photos / CCTV footage

If you feel this person requires further assistance, please recommend they attend A&E.

Were there any witnesses?^*

Yes No

If yes, please provide witness name and contact details

Is CCTV footage available of the incident?

Yes No

Notes

Data Protection Agreement^*

I agree