IRF 5.0 - Betws y Coed

IP's full name
First NameLast Name
IP's age (IF UNDER 18, ENTER SUPERVISING ADULT BELOW)
Supervising adults name
First NameLast Name
Address
House number or name
Street Address Line 2
Street nameTown/City
Post code
Phone Number
Please enter a valid phone number.Format: (00000) 000000.
Contact Email
IP/Guardian signature required
I am content that the information entered into this form is a true and accurate account of events
IP / Guardian signature
Your position/role

Non Injury Categories
Near Miss		Category 0
An event or dangerous occurrence that does not lead to harm but has the potential to cause injury or property damage		A non-injury event e.g. Fire, Confrontation, flood
Events involving an injury
Category 1	Category 2	Category 3	Category 4
An injury requiring first aid but does not prevent the Injured Person from continuing with their activity. i.e. minor cut or bruise.	An injury requiring first aid that prevents the Injured Person from continuing with their activity & where further medical advice may be advised. i.e. Sprained ankle, medium impact etc.	An injury that requires professional medical intervention to rectify. i.e. Fractures, Dislocations, Ligament damage etc	An injury that may be life changing to the Injured Person or even result in death. i.e. Paralysis, nerve damage, limb amputation etc

Incident Report Form - Betws y Coed