ࡱ> \^[7 9 bjbjUU !b7|7|Ml2222222~8L XD~k-j,,,,,,,$. 0-2-22%-22,,lf!:V&,22& py~& & ;-0k-&R121&F f2222PersonsReporting NameIncidentee NameContact Incidentee contactMembership noMembership noRoleIncidentee DOB Witness NameWitness NameContactContactMembership noMembership no IncidentDateTimeLocationEvent Injuries / DamageTick all that applies Was the injury -Yes NoDamage to equipment YesNoA fatality?Non club/3rd party equipment?Major injury or condition?Equipment destroyed / permanent loss?Required medical attention? Damaged but repairable?Unconscious? Minor repair?Need Resuscitation? Cosmetic damage?Hospital> 24 hours? Details of equipmentHospital/GP Visit? 1st aid given? (See below)Details including qualification(s) of giver. None of above Incident TypeTick all that appliesContact with equipment/item while involved in activity?Drowning/AsphyxiationContact with equipment/item while NOT involved in activity?TrappingHit by moving/flying/falling object Fire / ExplosionHit by moving vehicleElectrocutionInjured while handling/lifting/carryingExposed to or contact with harmful substanceSlip/Trip/Fall from same heightInjury by animalSlip/Trip/Fall from height Physical assault by personPlease give height____ mOther see details DetailsGive as much information as you can e.g. Name and role of persons, events leading to incident, name and type of any substance or equipment involved.  Actions / RecommendationsDescribe any and all actions that have been taken to prevent a similar incident.  Continue on additional sheet if necessary and return to the club safety officer. (Witnesses can complete a separate page).Date & Sign  TCC Incident & Near Miss Report Form. Next Review Date: (AGM) Feb 2008 `lnxz -0EGX[pr,-.}%'} ' ? 9 B*ph5\aJmH sH  B*ph 5H*\5\L )*$IfY$$Ifl4p##064 la$If 8 *+345HIJXY|SJSSSY|S $$Ifa$$If$$Ifl\3+]p# 2 064 laXYghino~S\$$Ifl\3+]p# 2  064 la$IfWUOOOO$If$$Ifl4\3+]p# 2 064 laYLSSSHY|SS  o#$If$If$$Ifl\3+]p# 2 0#64 laSQK$If$$Ifl\3+]p# 2 0#64 la$If+t$$Ifl03p#=  064 la$IfY$$Ifl4p##064 la,t$$Ifl03p#=  064 la$If $Ifv$$IflF03p#=  064 la)`Y$$Ifl4p##064 la$Ift$$Ifl03p#=  064 la'(9?BX\_Y$$Ifl4p##064 la$If_`l$If$$Ifl4ֈ up#   <064 lalmn$If+%%%$If$$Ifl4ֈ up#   (064 la%$$Ifl4ֈ up#   (064 la$If  $If+!  & F$If$$Ifl4ֈ up#   (064 la-./$If/0E+!  & F$If$$Ifl4ֈ up#   (064 laEFGXYZ$IfZ[p+!  & F$If$$Ifl4ֈ up#   (064 lapqrK`A  & F$If$$Ifl4\ p#  (064 la$If]|S  & F$If$$Ifl4\ p# `  064 la$Ifc]]$If$$Ifl4\ p#    064 la~~~~~x$If  o#$Ifu$$Ifl40p#$   064 laH$If  & F$Ifl$$Ifl40p#$ 064 lac]W$If o#$$Ifl4\ p#    064 la-.fg}~\EDY$$Ifl4p##064 la$IfY$$Ifl4p##064 la~Y SSSSYSSS$If$$Ifl\ p#D  064 la %&'OPSS`$$Ifl\ p#D  064 la$If P}~SS$$Ifl\ p#D  064 la$If     SI & F$If$$Ifl\ p#D  064 la$If   & YWQ$If$$Ifl\ p#D  064 la& ' X?@ABCDEFGHIJLMNOPQRTUVWXYZ]Root Entry F _1Table21WordDocument!bSummaryInformation(KDocumentSummaryInformation8SCompObjjObjectPool    FMicrosoft Word Document MSWordDocWord.Document.89q