Incident/Near Miss Reporting Form Report an incident or near miss on any kind of session within 24hrs of the event EVEN IF you have disucssed it verbally with the office. The time of submitting this report is recorded automatically.For events involving emergency services please call the office as soon as possible to inform the Operations Manager or Project Manager AND submit this form within 24hrs. Complete this form all in one go- you cannot save as you go along, and if you leave it half-filled it will time out after a short amount of time and you will lose what you have written. Your Name(Required) Other Bikeworks staff at the session Date of incident(Required) MM slash DD slash YYYY Time/Approx time of incident Hours : Minutes AM PM Nature of incident/ near miss(Required)Select OneInjury to person- particpant/ service userInjury to person- Public/ Third partyInjury to person- Bikeworks staff/ VolunteerTheft/ Loss/ Damage to Bikeworks propertyTheft/ Loss/ Damage to 3rd party propertyMissing Person (service user)OtherLocation of incidentAdd address and postcode if you know it/if relevant. EG 'CentralPark' will do. Location Post code (if known) Location type(Required)Select OneOn RoadOff Road (park, playground etc.)Indoor location- Bikeworks training roomIndoor location- non Bikeworks (eg client office, school premises etc)Which Session type were you working on(Required)The relevant Project Manager will automaticaly recieve a copy of the incident report and may contact you for further info. All Ability Cycling for Wellbeing / social cycling RSBS / Cycle taxi 1-2-1, Family, Group or School cycle training Maintenance training / Dr Bike E-Cargo Bike training E Scooter / E-bike training Instructor Training Ride Leader Training Inclusive Cycling/ SEND CPD None of the above/ Other Were Emergency Services Called?(Required)No Emergency ServicesAmbulancePoliceFireEmergency services reference number/notes (if applicable)EG Ambulance running number, incident report number, PC ID number. Name of person impacted:(Required) Phone of Impacted person(Required)Were they injured?(Required) Yes No Don't know Notes on Impacted person(Required) E-scooter / E-Bike serial number (E-scooter/bike training only) Was Impacted person wearing a helmet? (if applicable)YesNoName of third parties (1/2) Phone third parties (1/2)Notes on Third parties (1/2) Name of third parties (2/2) Phone third parties (2/2)Notes on Third parties (2/2) Decribe the IncidentBEFORE...DURING....AFTER(Required)BEFORE What activities were taking place? Did anything significant happen in the lead up to the incident? DURING How did it unfold?...What was the nature of any injuries?...... AFTER What action did you take next? Were guardians invovled/ informed?...... Was first aid used?....did you continue with activities? ACTIONS to prevent recurrence(Required)Anything you would do differently in future? Anything the office could do differently in future? Upload a file (OPTIONAL)Photos of the area/ damage/ injuries/ third party reports, anything useful.Max. file size: 50 MB.Office staff section:ACTIONS to prevent recurrence (OFFICE STAFF TO COMPLETE later)The PM recieving this report will add their own notes/ organisational actions (if any) Δ
