Vulnerable Accident / Incident Report Form 

Please telephone the CHSG Chair as soon as possible to notify details of the incident

This notification of incident form will be submitted to the CHSG Chair

The Chair will then take the appropriate action

This form will be reviewed at the next Trustees meeting to ascertain any actions thought to be appropriate

Vulnerable Adult

Accident Date/Time

If you have answered yes to any of the questions above you are strongly recommended to seek medical advice before using gym facilities.

Emergency Contact Details

I declare that I am not aware of any medical reason why I should not use the exercise facilities at this Centre.


I understand that I use the facilities at my own risk and that I agree to adhere to the centre's rules and etiquette and use the equipment in the manner I have been shown in order to prevent injury to myself or others and damage to the equipment.

Accident Details

Witnesses

Emergency Services Details

Signature of CHSG Member making report:

St. Columba's Church Hall, Plas Newton, Chester, Cheshire, CH2 1SA, Tel: 01244 535788

Registered Charity 1123789