Injury Report Form

Report an Injury or Near Miss

This form must be completed by all Society or Sports committee Leaders in the event of any incidents or near-misses at their events immediately. 

This includes the injury or near-misses of students, staff, external visitors like spectators or speakers.

A copy will be retained by London Metropolitan University Students’ Union. 

Nature of Report

Please describe the injury or near-miss?

What was the date of the Incident (DD/MM/YYYY) 

Your Details

Your name 

Student ID Number 

Contact Phone Number 

Your Club/Society  

Your Role  

Their Details


Contact Number 

Relationship to Club or Society (e.g member, spectator) 

If you have been unable to provide any of the information required above, please recount to the best of your knowledge their relationship to the Society or Sport and any information that might aid their identification. 


Where did this happen? If this occured in a specific room, please provide the room number and campus. If this happened off campus, simply indicate off campus. 

Details of Incident

Recount what happened to the best of your knowledge:

Please list any injuries that occured:

Did they lose conscienceness?

Yes  No 

Were they able to return to play afterwards?

Yes  No 

Was treatment given or administered?

Yes  No 

If yes, what treatment was given?

Witness Details


Contact Number 

Relationship to Club/Society 

If you are unable to provide any of the required information above, please detail to the best of your knowledge any attendee to the event who may act as a witness if required. 


  • I agree to the best of my knowledge this is an accurate and complete description of what transpired when the injury/near-miss took place 

  • I consent to the usage of the telephone number provided while this matter is investigated 

  • I confirm that I completed this Form as soon as the injury/near-miss took place 


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