Post Code (must be completed): __________________
Telephone; Day: ______________________________________________________________________________
Evening: _____________________________________________________________________________________
Mobile: ______________________________________________________________________________________
Current / Previous Clubs
Current Club Name ; ___________________________________________________________________________
Position held and Responsibilities; _______________________________________________________________
Start and Leaving Date; ________________________________________________________________________
_____________________________________________________________________________________________
Present or Most Recent Employment/Role/Responsibilities; _________________________________________
_____________________________________________________________________________________________
Name of Employer/Managing Organisation: _______________________________________________________
Job Title: ____________________________________________________________________________________
Dates of Employment (month and year): __________________________________________________________
Principal Responsibilities: ______________________________________________________________________
Reasons for Leaving: __________________________________________________________________________
_____________________________________________________________________________________________
Qualifications and Previous Experience of Working with Children or Vulnerable Adults
(include name of organisation, responsibilities/duties, length of time involved and reasons for leaving)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Referees;
Please provide details of 2 referees. At least one should have knowledge of your previous work with children and/or vulnerable adults. These individuals may be contacted for the purposes of verifying the information contained in this form.
Name: (1st) _________________________________________________________________________________
Organisation: ________________________________________________________________________________
Address: ___________________________________________________________________________________
Telephone:__________________________________________________________________________________
Relationship to Applicant; _____________________________________________________________________
Name: (2nd) ________________________________________________________________________________
Organisation: _______________________________________________________________________________
Address: __________________________________________________________________________________
Telephone: ________________________________________________________________________________
Relationship to Applicant: ____________________________________________________________________
Additional Information;
Please provide details of relevant experience, principal achievements, personal skills and qualities, voluntary work and explain how you might use them in this post.(Use a separate sheet if necessary).___________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
I am aware that in accordance with the Data Protection Act 1998, information provided on this application form will be stored for the purposes of processing the data for recruitment and monitoring the recruitment process. If appointed I am aware that this information will be stored for the purposes of enabling relevant organisation procedures.I have completed this form accurately and truthfully and to the best of my knowledge.
Signature: _____________________________________________ Date: _______________________________
Declaration of Designated Person;
I confirm that I have seen the following identification documents relating to
[insert name of applicant]: _____________________________________________________________________
I confirm to the best of my ability that the identification documents are accurate.
Signed: ______________________________________________ Name ______________________________
Date: _________________________________________________
Appendix C
Scottish Clay Target Association Ltd; Reference Form
The S.C.T.A. is committed to ensuring that all members in positions that require contact with children or vulnerable adults are suitable to do so. In accordance with the S.C.T.A.s Child and Vulnerable Adult Protection Policy, references are sought for all members whose position requires contact with children and/or vulnerable adults.
Details of Referee;
Name: ___________________________________________________________________________________
Address:__________________________________________________________________________________
__________________________________________________________________________________________
Organisation: ______________________________________________________________________________
Telephone: _______________________________________________________________________________
Relationship to Applicant: ___________________________________________________________________
[Name of applicant] __________________________________________ has expressed an interest in working with the S.C.T.A. and has given your name as a referee. This post involves substantial/occasional (delete as appropriate) access to children, young people and/or vulnerable adults. As an organisation committed to the welfare and protection of children, young people and vulnerable adults we are anxious to know, -is any reason what-so-everl to be concerned about this applicant being in contact with children, young people or vulnerable adults?
YES/NO (Delete as appropriate)
If you have answered yes we will contact you in confidence, otherwise please continue.
All the information on this form will be treated confidentially and in accordance with relevant legislation and guidance. Information will only be shared with the person conducting the assessment of the applicants suitability for the position and the immediate supervisor should they be offered a position.
We would appreciate you being extremely candid in your evaluation of this person.
How long have you known this person? ________________________________________________________
In what capacity? ___________________________________________________________________________
What attributes does this person have that would make them suited to work with children, young people or vulnerable
adults? ____________________________________________________________________________________
__________________________________________________________________________________________
Please rate this person on the following (please tick one)
Not Good Good Very Good Excellent
Responsibility ____________________________________________________________________
Maturity ____________________________________________________________________
Self Motivation ____________________________________________________________________
Can motivate others ____________________________________________________________________
Commitment ____________________________________________________________________
Energy ____________________________________________________________________
Trustworthiness ____________________________________________________________________
Reliability ____________________________________________________________________
Please comment on the performance of the individual in the following areas:
Honesty/trustworthiness; ______________________________________________________________________
Reliability; __________________________________________________________________________________
Relationships and communication with internal and external colleagues; _____________________________
___________________________________________________________________________________________
Team working; _____________________________________________________________________________
Sickness absence; _________________________________________________________________________
Adherence to organisation procedures. _________________________________________________________
Please provide any other details about the person that are relevant to the position they have applied for
(please use a separate sheet if required):_______________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I am aware that the information given will be processed in accordance with the Data Protection Act 1998, for the purposes of recruitment of the named individual.
Signed: ______________________________________________ Name: ____________________________
Date: _____________________________________________________________________________________
Thank you in advance for the information provided and the time spent in compiling the report.
Please return this form in an envelope marked PRIVATE and CONFIDENTIAL to:
Mr R Wright ( CPPO )
Scottish Clay Target Association
PO Box 246
Wide Open
Newcastle-upon-Tyne
NE13 6YU
Appendix D
Scottish Clay Target Association Ltd; Self-Declaration Form
As required in the S.C.T.A.s Child and Vulnerable Adults Protection Policy and Procedures this form must be completed by all members for positions that require contact with children and/or vulnerable adults.
The S.C.T.A. is committed to the protection of children and vulnerable adults involved in sport and have a duty to ensure the suitability of any individual who works with children and/or vulnerable adults. To fulfil this responsibility, we ask that you complete this form having read the guidance notes attached.
Note: You are advised, under the provisions of the Rehabilitation of Offenders act 1974 (exceptions) order 1975 as amended by the Rehabilitation of Offenders Act 1974 (Exceptions Amendment) Order 1986, to declare all convictions including 'spent' convictions.
Should you be appointed for the position applied you will also be required to provide a Standard/Enhanced disclosure under the terms of the Police Act 1997 (Part V).
o For positions that require a Standard check: if selected for an interview you will be required to disclose all convictions (spent and unspent).
o For positions that require an Enhanced check: if selected for an interview you will be required to disclose all convictions (spent and unspent), cautions, warnings and any other non-conviction relevant information.
The S.C.T.A. undertakes to treat all applicants for positions within the S.C.T.A. equally and to process and make decisions on disclosed information in a fair manner.
Please complete Sections 1 and 2 fully including all relevant details regarding convictions, investigations (if applicable), social work or social department investigations and disciplinary action.
SECTION 1
PART A
Previous Convictions (to be completed for positions requiring Standard or Enhanced checks)
(continue on a separate form if necessary)
Date: _________________________________________________________
Court: _________________________________________________________
Offence(s)originally charged with: ____________________________________________________________
Sentence: ________________________________________________________________________________
Please give details of the reasons and circumstances that lead to your offence(s):
_________________________________________________________________________________________
_________________________________________________________________________________________
Please give details of how you completed the sentence imposed (e.g. did you pay your fine as required, what conditions were attached to your probation/community service order, did you comply with the requirements of your order/custodial sentence):
_________________________________________________________________________________________
_________________________________________________________________________________________
Do you give the S.C.T.A. permission to contact the above organisations to clarify the information disclosed?
_________________________________________________________________________________________
What have you learned from the experience?__________________________________________________
_________________________________________________________________________________________
PART B
You must complete this section if the position applied for requires an Enhanced check;
Previous Police Investigation (continue on a separate form if necessary)
_________________________________________________________________________________________
Date of investigation: ______________________________________________________________________
Police Division involved: __________________________________________________________________
Investigation(s) details: Please give details of the reasons and circumstances that led to your investigation:
_________________________________________________________________________________________
Disposal (if known):________________________________________________________________________
Are you, or have you ever been, known to any Social Work Department/Social Services Department as an actual or potential risk to children: YES/NO
If yes , please provide details: _______________________________________________________________
_________________________________________________________________________________________
PART C
Have you ever had a disciplinary sanction (from a sports or other organisations governing body) relating to inappropriate behaviour with children/vulnerable adults or child abuse? YES/NO
If yes , please provide details:_______________________________________________________________
_________________________________________________________________________________________
SECTION 2
I hereby declare and represent that, save as disclosed above I have not at any time, whether in the United Kingdom or abroad, been found guilty and sentenced by a court for a criminal offence.
I give my consent to the S.C.T.A. to carry out a check with Disclosure Scotland (if deemed necessary) and to take up references for the purposes of verifying the replies given in this declaration, including enquiries of any relevant authority.
I agree to advise the S.C.T.A. should I be convicted of an offence after the commencement of my employment with the S.C.T.A. and that failure to do so may lead to the immediate suspension of my work with children in the S.C.T.A. and the termination of my services and in certain cases, membership.
I agree to abide by the S.C.T.A.s Code of Practice for the Protection of Children and Vulnerable Adults.
I agree to abide by the conditions above and certify that the information contained in this form is true and correct to the best of my knowledge and I realise that false information or omissions may lead to the immediate suspension of my work with children in the S.C.T.A. or the termination of my services.
Signed: ________________________________________________ Date: ________________________
Note: the information contained in this form will be managed in accordance with the terms of the Data Protection Act 1998
Appendix E
Scottish Clay Target Association Ltd; Guidance Notes for Completing Self-Declaration Form
The S.C.T.A. is committed to the protection of children and vulnerable adults involved in sport and have a duty to ensure the suitability of any individual who works with children and/or vulnerable adults. The information provided in the Self-Declaration Form, in addition to the other recruitment and selection procedures detailed in the S.C.T.A.s Child and Vulnerable Adult Policy and Procedures, will enable an informed decision to be made about an individual's suitability to work with children and/or vulnerable adults.
Who must complete the Self-Declaration Form?
This form must be completed by all applicants for positions:
o Listed in the rehabilitation of Offenders Act 1974 (ROA)(Exceptions) Order 1975 i.e. positions by which an employer is entitled to ask an 'exempted question'. These positions include occupations with duties that involve regular contact with children and young people (under the age of 18) and vulnerable adults.
o Which involve regular contact with and caring for, training, supervising or being in sole charge of children or young people.
What happens if I do not wish to complete a Self-Declaration Form?
In accordance with the S.C.T.A.s Child and Vulnerable Adult Policy and Procedures, all applicants for the above types of post must complete a Self-Declaration Form. Anyone unwilling to do so must not be employed in a position that requires regular or unsupervised contact with children or vulnerable adults.
Why must I give information about previous convictions?
The law states that for certain types of employment applicants are required to disclose information about their background to help determine whether they are suitable for the post. Jobs that involve working with children, young people and vulnerable adults fall into this category.
What information do I have to put on the Self-Declaration Form?
This depends on the type of post you are applying for. The Job Description (including information on roles and responsibilities) provided with the Application Form tells you what kind of post this is.
If the post involves regular contact with children, young people or vulnerable adults:
o complete Part A and C only and sign the form at Section 2
o give details of all offences of which you have been convicted by a court both in the UK and abroad regardless of when the conviction(s)occurred (this means you should include both 'spent' and 'unspent' convictions)
If you are applying for a post that requires regularly caring for, training, supervising or being in sole charge of children or young people:
o complete Part A, Part B and Part C and sign the form at Section 2
o give details of all offences of which you have been convicted both in the UK and abroad, regardless of when the conviction(s) occurred
o give details of any cautions, charges or warnings issued by the police (this is called non-conviction relevant information)
You must also provide identification so that the personal details you provide can be verified.
Who gets to read the Self-Declaration Form?
The Self-Declaration Form should be sent to the S.C.T.A. in a sealed envelope. If you are not chosen for interview, the envelope will be returned to you, unopened, for you to dispose of.
The envelope will be opened if you are being considered for interview. If you are selected for interview and you have recorded previous convictions or other relevant information, you will be given the opportunity to discuss this at the interview.
What happens to the Self-Declaration Form after a decision has been made on my application?
If you are unsuccessful the Self-Declaration Form will be returned to you for you to dispose of.
If you are successful, police checks will then be carried out. The Self-Declaration Form and the Police Checks can be retained until a decision has been made on your application. Usually it will not be held any longer than six months.
Appendix F
Scottish Clay Target Association Ltd; Guidance on Disclosure Scotland Checks
Recent changes in the laws have enhanced the ways in which employers and organisations can take steps to ensure that people who work with children and vulnerable adults are suitable for such positions. The following provides answers to commonly-asked questions.
Do I have to employ people with previous convictions?
The Rehabilitation of Offenders Act 1974 provides that after a certain amount of time, a conviction will be regarded as 'spent'. This means that in certain circumstances, a potential employee does not have to declare this conviction. It is illegal to discriminate against someone on the grounds of a spent conviction.
Exceptions to this rule
For certain kinds of employment, a prospective employer can ask you to declare all spent and unspent convictions. These are known as 'exempted' and are listed in the Rehabilitation of Offenders Act 1974 (ROA)(Exceptions) Order 1975. This includes nurses, teachers, firearms dealers, solicitors, positions which involve contact with children, the elderly and vulnerable adults.
How can I ask people about their previous convictions?
For positions that involve contact with children and vulnerable adults, applicants should be made aware that such positions are exempted i.e. they will be asked to declare all convictions. As part of your recruitment and selection procedures all members should complete an application form and a self-declaration form. The self-declaration form provides an opportunity to declare convictions and is confidential (see recruitment and selection procedures). The interview process enables you to identify the person you wish to appoint. At this point you should apply for a Disclosure Scotland check. This will verify or otherwise the information contained in the self-declaration form.
How can I get access to criminal records information?
Part V of the Police Act 1997 changed the procedures for checking criminal records. Organisations can apply for criminal records information to Disclosure Scotland. Disclosure Scotland began operating as part of the Scottish Criminal Records Office in Scotland on 29th April 2002.
To access a Disclosure Scotland check, organisations must firstly register with Disclosure Scotland. Each registered body will have to pay a fee of £150 to register with an additional £10 per named person for countersigning applications for a Disclosure Certificate.
Each Disclosure application, at present, costs £13.60. As it is an individual who applies for a check, Disclosure Scotland suggests the applicant should pay this however it is recommended that the organisation considers and makes a decision on who pays for all Disclosure applications.
Unpaid volunteers in the voluntary sector can access free Disclosures through the Central Registered Body for Scotland (CRBS) run by Volunteer Development Scotland.
Types of Disclosure Certificates;
1 Basic Disclosure
A Basic Disclosure Certificate is issued to the individual applicant only and is available to anyone on the payment of the appropriate fee. This provides information about current (unspent) convictions only. It does not contain any other information contained in criminal records.
2 Standard Disclosure
Standard Disclosures are only available for exempted positions (see above). This includes positions that involve regular contact with children and young people and vulnerable adults.
Standard Disclosures can only be applied for through a Registered Body and the Lead or Counter signatory of the Registered Body must countersign all applications.
A copy of the Standard Disclosure Certificate will be sent to both the applicant and the relevant Registered Body. The Standard Disclosure contains information about spent and unspent convictions.
3 Enhanced Disclosures
Enhanced Disclosures are only available for exempted positions and those that involve a greater degree of contact with children or vulnerable adults. This includes those who regularly care for, train, supervise, or are left in sole charge of children, young people and vulnerable adults.
Enhanced Disclosures can only be obtained through a Registered Body and the Lead or Counter signatory must sign the application form.
A copy of the Enhanced Disclosure Certificate will be sent to both the applicant and the Registered Body. The Enhanced Disclosure reveals details of all spent and unspent convictions and may also include non-conviction information held locally by the police, where this is considered relevant to the post or voluntary work sought.
How do I know which level of check is required?
Employers and organisations must advise applicants of the level of Disclosure required for the post. Details of the post must be provided in the Disclosure Scotland application form.
Is more than one Disclosure required?
For people who work in more than one different area e.g. Club and Local Authority, it is possible that more than one check will be required. At present there is no guidance or rule about this and each employer must decide whether another check is necessary. A Certificate issued for one post may not be appropriate for another. Only applicants have the right to show their Disclosure Certificate to whomever they choose.
What happens to the Disclosure Certificate?
Disclosure Scotland recommends the Disclosure Certificate be destroyed after a decision on recruitment has been reached. They must not be kept any longer than 6 months.
What if the information on the Certificate is incorrect?
Disclosure Scotland has provided an appeals procedure to challenge the accuracy of the information on the Certificate.
(Important Note: At first the process for obtaining a Disclosure Scotland check may seem very straightforward, however the process and implementing it into procedures are likely to have a number of implications for each individual organisation. At present, checks are not compulsory and it is strongly recommended that each organisation spends time considering the implications of registration and managing Disclosure checks).
For further information see www.disclosurescotland.co.uk and www.vds.org.uk
Appendix G
Scottish Clay Target Association Ltd; Medical Consent Form
Consent To Medical Treatment
The following information and consent is requested to ensure the health and well being of all children and vulnerable adults participating in S.C.T.A. activities. The information contained in this form is confidential and will only be used to safeguard and promote the child/vulnerable adult's health and well being should the need arise.
Name of Child/Vulnerable Adult: ____________________________________________________________
Date of Birth: _____________________________________________________________________________
Name of General Practitioner: _______________________________________________________________
Address: ________________________________________________________________________________
_________________________________________________________________________________________
Telephone: _____________________________________________________________________________
Please provide details of any pre-existing medical conditions that may affect the child/vulnerable adult's participation in
the activity/event/programme: ______________________________________________________________
_________________________________________________________________________________________
Details of any medication or treatment required: ________________________________________________
_________________________________________________________________________________________
Details of any existing injuries (include when injury occurred and the treatment received): _____________
_________________________________________________________________________________________
Details of any allergies, including allergies to medication: _______________________________________
_________________________________________________________________________________________
Child/Vulnerable Adult (optional)
I [insert name] _________________________________ consent to receiving medical treatment, including anaesthetic, which the medical authorities present consider necessary.
Signature: ______________________________________________
Print Name: _____________________________________________ Date: ____________________________
Parent/Guardian/Legal Carer;
I [insert name of parent/guardian/carer] ___________________________________ consent to [insert name of
child/vulnerable adult] ________________________________________________receiving medical treatment, including anaesthetic, which the medical authorities present consider necessary.
I undertake to inform the S.C.T.A. should any of the information contained in this form change.
Signature: ______________________________________________
Print Name: ____________________________________________ Date: ___________________________
Relationship to child or Vulnerable Adult: ________________________________________________________
Appendix H
Scottish Clay Target Association Ltd; The Law and Medical Consent: Children and Vulnerable Adults
In some cases it may be necessary to obtain consent for medical examination, treatment or procedure to a child or vulnerable adult e.g. where an injury has occurred in the course of training or competition or where it is alleged that the child has been abused.
The purpose of this guidance is to provide an overview of the law in Scotland in relation to medical consent and to advise the S.C.T.A. members on the best practice that must be followed.
Children - Who can give consent?
The child
The Age of Legal Capacity (Scotland) Act 1991 allows children under the age of 16 to give their own consent in certain circumstances. Section 2(4) states:
A person under the age of 16 shall have legal capacity to consent on his/her own behalf to any surgical, medical or dental procedure or treatment where, in the opinion of a qualified medical practitioner attending him, he is capable of understanding the nature and possible consequences of the procedure or treatment.
The decision about competence is entirely one for the doctor or other medical practitioner to make. This means where a child is assessed as being capable of providing consent, the consent of a parent/guardian is not required.
The Scottish Executive recommend that efforts should always be made to discuss with the child informing his/her parents/guardians or carers, except where it is clearly not in the child's best interests to do so. If a child refuses to allow parents/guardians or carers to be informed, then this must be respected.
Consent from the following categories would only be required where the child is assessed as incapable of providing consent.
Person with Parental Responsibilities in relation to the child.
A person who has parental responsibility of the child would normally be requested to provide consent, as under the Children (Scotland) Act 1995 they have responsibilities that include a duty to safeguard and promote the child's health, development and welfare.
If a child's parents are or have been married to each other, both have parental responsibility and either can give consent. If the parents have not been married to each other, normally only the mother has automatic parental responsibility including the right to consent. The father will have the right to consent if either:
o He has obtained an order from the court awarding him parental responsibilities.
o He and the child's mother have a registered parental responsibilities agreement.
Where a parent requires to provide consent they should, so far as practicable, consider the views of the child.
Person who has care and control of the child
Section 5 of the Children (Scotland) Act 1995 also allows consent to be given by those who have care or control of a child but who do not have either parental responsibilities or parental rights in respect of the child e.g. a grandparent who is the child's main carer. These people have a duty to do what is reasonable in all the circumstances to safeguard the child's health, development, and welfare. This includes giving consent to treatment or procedures.
Such consent would not be effective however, where;
o The child is capable of consenting
o The person knew that the parent would not consent e.g. a parent who is a Jehovah Witness
o The medical examination was for the purpose of establishing child abuse
If the child is looked after by the Local Authority, the authority can give consent only if it has obtained a Parental Responsibilities Order from the court or consent is authorised by conditions attached to an order or warrant issued by a Court or Children's hearing.
Vulnerable Adults - Who can give consent?
As with children, where a vulnerable adult is capable of consenting to medical treatment, consent will not be required from any other individual such as parent/guardian or carer. Again, it is for the medical profession to determine whether the vulnerable adult is capable of understanding the proposed treatment and consequences.
There are safeguards where a vulnerable adult may not be capable of consenting to medical treatment. This is dealt with in Part 5 of the Adults with Incapacity (Scotland) Act 2000.A medical practitioner must certify that he is of the opinion that an adult is incapable in relation to a decision about medical treatment. They shall then have the authority to do what is reasonable in the circumstances in relation to the proposed medical treatment to safeguard or promote the physical and/or mental health of the adult.
Appendix I
File Ref ________________
Scottish Clay Target Association Ltd . Notification of Accident
Staff/Student/Visitor All questions must be answered
(Please delete whichever is inappropriate) (Complete the appropriate section including C)
To _______________________________________________ Group _______________________________
From ____________________________________________ Date _______________________________
(A)
Complete for Accident to Staff (including temporary or casual staff)
Name of injured person ____________________________________________________________________
Dept/Division ____________________________________________________________________________
Job Title _________________________________________________________________________________
Date of Accident ___________________________________ Time of Accident ______________________
Date Reported ____________________________________ Time Reported ______________________
Time injured person actually stopped work on day of accident _____________________________________
Time should have stopped work on day of accident _____________________________________________
Time injured person re-commenced work on day of accident _____________________________________
(B)
Complete for Student/Visitor (Delete appropriate)
Name of injured person _____________________________________________________________________
Home Address ____________________________________________________________________________
Reason for visit to [name of organisation] ______________________________________________________
Date of Accident ___________________________________ Time of Accident ______________________
Date Reported ___________________________________ Time Reported ______________________
(C)
Complete for all Accidents (Where not applicable, please indicate)
Nature and extent of injuries where known (state left or right where applicable;
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
How did accident happen? (Full description of incident);
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Where did the accident occur? (Precise Location);
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Was accident due to lifting by hand? Yes / No
If Yes
Total estimated weight of load lifted; ___________________________________________________________
How many other persons assisted with the lifting? ________________________________________________
Was accident caused by machinery? Yes / No
If Yes
The name and type of machine; ______________________________________________________________
Part causing injury; ________________________________________________________________________
Whether in motion by mechanical power at the time? ____________________________________________
Was accident relative to a fall of persons, material, plant etc? Yes / No
If Yes
What material? ____________________________________________________________________________
Complete for all Accidents (Where not applicable, please indicate)
Was accident caused by faulty plant/equipment? Yes / NO
If Yes
What plant/equipment failed? ________________________________________________________________
How plant/equipment failed? ________________________________________________________________
Was accident caused by fault of any person? Yes / No
If Yes
Name, if known; __________________________________________________________________________
Nature of fault; ___________________________________________________________________________
What exactly was the injured person doing at the time of the accident? _____________________________
_________________________________________________________________________________________
Was he/she authorised or permitted to do this Yes / No
Was this a written down procedure? Yes / No
If not, was this custom and practice? Yes / No
Were general or specific instructions given prior to commencement? Yes / No
If so, state what instructions and by whom given; ________________________________________________
__________________________________________________________________________________________
Complete for all Accidents (Where not applicable, please indicate)
Was protective clothing or equipment necessary for the activity being undertaken at the time of the accident?
Yes / No
If Yes
Give description of such protection; ___________________________________________________________
Was it provided? Yes / No
If yes when? ___________________________________________________________________________________
Was it being used at the time of the accident? Yes / No
If no , why? ________________________________________________________________________________
Has the accident been entered in the Departmental Accident Book? Yes / No
Did injured person report to First Aid Post/Surgery? Yes / No
If Yes
At what time _______________________________________________________________________________
Accompanied by anyone? Yes / No
If Yes ,
By whom? __________________________________________________________________________
State name(s)of witness(s) __________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Have You;
Obtained a statement from each witness? Yes / No
If Yes , please attach.
Drawn a sketch or taken a photograph showing location and people? Yes / No
Kept the offending tool/implement? Yes / No
If Yes , what has been kept and where? _______________________________________________________
_________________________________________________________________________________________
Person Completing Form
Signatures _______________________________________ Date _____________________________
Director/Principal/Organiser
Signatures _______________________________________ Date _____________________________
Please do not delay completing and sending this form and follow up with photographs, sketches and statements as
necessary.
Appendix J
Scottish Clay Target Association Ltd; Notification of Incident Form
This form must be completed where members are concerned about an incident involving a