WHMC Incident Report Form Please use this form to record any incidents or significant events, that adversely affect Members or Visitors attending the Wiveliscombe Masonic Hall Club (WMHC) premises. Additional guidance on incident reporting is available via the web site: 6209.co.uk/incident. If you are unsure or need further help, please contact: info@6209.co.uk This form should be completed and handed to the Person in Charge for reporting and filing. Date TimeHH : MM Location within WMHC site Brief Description of incident Witnesses to Incident Names of persons involved Nature and extent of any injuries If any injuries required treatment by a medic or hospital, give details: Provide a detailed description of how the accident occurred including contributing factors: Describe the immediate actions taken to address the incident and provide assistance: What measures could be implemented to avoid similar incidents in future? Report completed by: Capacity in which acting: Please indicate:Evacuation chair used?Significant blood loss?AED used? Word Verification Incident Reference Number:SubmitReset
