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DofE incident / accident report – June 2012 - Rev 3
Incident/accident reportAs a Licensed Organisation you have committed to ‘notify ASL or the Charity immediately in the event of any serious incident or accident that leads to or could have led to injury of a participant or Staff’. Clause 3.10. Please fill in the form below and email it to [email protected] and cc your relevant DofE Regional/Country office. Filling in this form does not negate the need for you to inform the relevant Emergency Services and follow your Licensed Organisation’s emergency procedures.
DofE Region: Date of incident: Time: Type of incident: Accident
BehaviourIllness
LostNear missRecurring injury
Other Please give details below
Group details:Group name Contact name Position Address Telephone no. Email
Licensed Organisation details:LO name Contact name Position Address Telephone no. Email
Informant’s details (if different from groups’ details):Contact name Position Address Telephone no. Email
Casualty details:DofE Award level Bronze Silver Gold Section Expedition Volunteering Physical Skills Residential Age
What happened and to whom?
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DofE incident / accident report – June 2012 - Rev 3
Details of any injuries sustained and to whom
What has happened since?
Please email: [email protected] (please copy to relevant DofE Regional/Country office).Or forward to: Operations Administrator
The Duke of Edinburgh’s AwardGulliver HouseMadeira WalkWindsorSL4 1EU.
The DofE will keep this information confidential but will share it with the Licensed Organisation.
For internal use onlyDate received Received by Follow-up action
This is a reporting document; you should not expect a response from the DofE.
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